Florendo, Ron Matthew S.

01/21/20
NUR-1202 Sec-8 7:00-10:00 a.m.

Health Assessment Interview

An interview is a structured conversation with a purpose. It is used to collect patient
health information so patients can receive the care that they need.

What is the purpose of interview?

1. Get or give information
2. Identify problems of mutual concern
3. Evaluate change
4. Teach
5. Provide counseling or therapy

What is the structure of interview?

OPENING (or Introductory)
 Most important part of the interview, sets tone for the remainder of the interview
 Purpose is to establish rapport and orient the interviewee
 The nurse must be careful not to overdo this stage
 In this stage, the Nurse explains the purpose & nature of the interview, like what
information is needed, how long will it take, & what is expected of the client, how the
information will be used, & that the client has the right not to provide data.
BODY (Working)
• Client communicates what he or she thinks, feels, knows, perceives in response to
questions from the nurse.
• Effective development of the interview demands that the nurse use communication
techniques that make both parties feel comfortable & serve the purpose of the
interview
CLOSING (Summary and Closing)
• The nurse terminates the interview when the needed information has been obtained.
• In some cases, the client may terminates the interview
• Closing is important for maintaining the rapport and trust and for facilitating future
interactions.
What are the immunizations given to infants and adults?
Birth
1. Bacille Calmette-Guerin (BCG)
→ Tuberculosis
2. Hepatitis B

1 ½ - 2 ½ Month/s :
1. Pentavalent Vaccine (DPT-HEP B-HiB)
→ Dipterya
→ Tetano
→ Hepa B
→ Pertussis
→ Pulmonia
→ Meningitis
2. Oral Polio Vaccine (OPV)
3. Pneumococcal Conjugate Vaccine (PCV)
→ Pulmonia
→Meningitis

3 ½ Months:
1. Inactivated Polio Vaccine (IPV)

9 Months – 1 year old:

1. Measles, MUMPS, RUBELLA (MMR)
→ Measles
→ Mumps
→ German measles
 FOR CHILDREN-ADULTS:

1. Human Papilloma
- Immunocompetent adult female and male of 26 y/o.
2. Japanese Encephalitis
3. Meningococcal Vaccine
4. Rabies
5. Typhoid
6. Hepatitis A
7. Hepatitis B
8. Influenza
9. MMR
10. Pneumococcal
Elderly individuals in the age of 50 or greater.
11. Tetanus, diphtheria, acellular pertussis (TdaP)
12. Varicella
13. Cholera
14. Dengue
Immunocompetent adult clients 18-45 y/o
15. Herpes Zoster
60 y/o
Gordon’s 11 Functional Health Patterns
(1) Health Perception and Health Management Pattern
● Data collection is focused on the person's perceived level of health and well-being, and on
practices for maintaining health.
− What is your opinion about health?
− Are you immunized about seven target diseases?
− Last immunization?
− Do you have any allergy? If yes then type of allergy.
− Any surgery in past?
− What type of surgery?
− Last physical examination & for what purpose.
− Are you using any medicine recently?
− Do you know about these medicines?

(2) Nutrition and Metabolism Pattern

● Assessment is focused on the pattern of food and fluid consumption relative to metabolic
need.
− Ask about their skin, scalp and nails?
− What is your diet menu?
− Any food restriction regarding disease point of view?
− Any food restriction regarding religious point of view?
− Any food like or dislike?
− Any food allergy?

(3) Elimination Pattern

● Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems
such as incontinence, constipation, diarrhea, and urinary retention.
a) Urine:
− Color of urine, amount, frequency, odor and any discharge.
− Any urinary problem, dysurea, Anurea, Oligourea, , polyuria.
b) Defecation:
− Are you using any laxative? If yes which?
− Any problem during passing defecation?

(4) Activity and Exercise Pattern

● Assessment is focused on the activities of daily living requiring energy expenditure,
including self-care activities, exercise, leisure activities respiratory and cardiac system.
− Do you any breathing problem? In which apnea, hypoxia, hypoxemia, hypercapnia.
− Do you have cough? (Productive or non productive)
− Any changes in heart beat during exercise?
− Do you feel pale during exercise?
− What type of exercise you do or any problem during exercise?

(5) Cognition and Perception Pattern

● Assessment is focused on the ability to thinking, decision making, and problem solving.
− Orientation about time place and person.
− Any difficulty in sentence making? Loss of memory.

(6) Sleep and Rest Pattern

● Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional
sleep patterns, fatigue, and responses to sleep deprivation may be identified.
− Sleeping hour?
− Are you using nap (evening type sleeping).
− What do you feel after waking? (Fresh, headache, drowsy).
− Are you using any medication for sleeping?
− Do you have any exercise or walking at night?

(7) Self-Perception and Self-Concept Pattern

● Assessment is focused on the person's attitudes toward self, including identity, body image,
and sense of self-worth.
− What is your self perception about yourself?
− Are you satisfied with your self body image?
− Do you like grooming?

(8) Roles and Relationships Pattern

● Assessment is focused on the person's roles
in the family and relationships with others.
− What is your role in family?
− If you are in hospital then who will perform your responsibilities?
− All the family members are cooperative with you?
− Who is decision maker in your family?
(9) Sexuality and Reproduction Pattern
● Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns
and reproductive functions.
− When you first notice changes in your menarche (first menses is called menarche)
− Do you have any sexual problem? (loss of libido)
− Active sex (direct sex with male and female) Passive sex (sex without male and female
partner) Digital sex (Artificial dimy etc)
− Reproductive: Infertility

(10) Coping and Stress Tolerance Pattern:

● Assessment is focused on the person's perception of stress and on his or her coping strategies
Support systems are evaluated, and symptoms of stress are noted.
− If you have stress then what is your coping mechanism towards stress? Crying, angry,
violence, (what is your opinion regarding that)

(11) Values and Belief Pattern

● Assessment is focused on the person's values and beliefs (including spiritual beliefs).
− What is your religion?
− Do you offer prayer