2M Flashcards
- reportedly by the client
- may include S/S described by client but not noticeable to others.
- may include demographic information, patient and family information, past & current medical conditions, etc.
SUBJECTIVE DATA
- information that the health care professional gathers during a physical examination
- consist of information that can be seen, felt, smelled or heard by the HCP.
OBJECTIVE DATA
sensations or symptoms (e.g. – pain, hunger), feelings (e.g. – happiness, sadness), perceptions, desires, preference, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
SUBJECTIVE DATA
Observations and measurements made by the data collector based on an acceptable standard. data directly and indirectly observed through measurements
OBJECTIVE DATA
skills need to collect objective data
o Inspection
o Palpation
o Percussion
o Auscultation
PHASES OF THE INTERVIEW
PRE-INTRODUCTORY PHASE
INTRODUCTORY PHASE
WORKING PHASE
SUMMARY AND CLOSING PHASE
nurse introduces herself and reviews the medical records before meeting the client.
PRE-INTRODUCTORY PHASE
nurse explains the purpose of the interview, discusses the types of the questions that will be asked. Explains the reason for taking notes and assures the client that information will remain confidential.
INTRODUCTORY PHASE
the nurse elicits the client with comments about major biographical data, reasons for seeking care, history of patient’s present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practice, and lastly developmental level
WORKING PHASE
nurse summarizes information obtained during the working phase, validates problems & goals with the client
SUMMARY AND CLOSING PHASE
NON-VERBAL COMMUNICATION
APPEARANCE
DEMEANOR
FACIAL EXPRESSION
ATTITUDE
SILENCE
LISTENING
appearance should be professional
APPEARANCE
an overload aspect of communication
FACIAL EXPRESSION
one of the most important nonverbal skills to
develop as a health professional is a non-judgmental attitude
ATTITUDE
allows the nurse and the client to reflect and organize thoughts which facilitate more accurate reporting and data
collection
SILENCE
most important skill to learn and develop fully in
order to collect complete and valid data
LISTENING
VERBAL COMMUNICATION
OPEN-ENDED QUESTIONS
CLOSE-ENDED QUESTIONS
LAUNDRY LIST
REPHRASING
WELL-PLACED PHRASES
are used to elicit the client’s feelings & perception
OPEN-ENDED QUESTIONS
to obtain facts and to focus on specific information
CLOSE-ENDED QUESTIONS
to provide the client with a list of words to choose in describing symptoms, conditions/feelings
LAUNDRY LIST
effective way to communicate and validate during the interview
REPHRASING
the nurses can encourage verbalization by using well placed phrases
WELL-PLACED PHRASES
COMPONENTS OF A COMPLETE HEALTH HISTORY
biographical data
reasons for seeking health care
history of present health concern
personal health history
family health history
review of systems for current health problems
lifestyle and health practices
developmental level
personal data that distinguishes individual from one another.
biographical data
o chief complaint
o onset of present health concern
o duration
o course of the health concern
o signs, symptoms, and related problems
reasons for seeking health care
o allergies (reaction)
o serious or chronic illness
o recent hospitalizations
o recent surgical procedures
history of present health concern
personal topics such as sexual activities etc
personal health history
o pertinent health status of family members
o pertinent family history of heart disease, lung
disease, cancer, hypertension, diabetes, obesity, mental illness, genetic disorders
family health history
o activity/exercise, leisure and recreational activities
o Sleep/rest
o interpersonal relationships/resources
o coping and stress management
o environmental hazards
lifestyle and health practices
o current significant physical and psychosocial changes/issues
developmental level
promote effective communication among multi- disciplinary health care team members and to facilitate client care
DOCUMENTING DATA
ASSESSMENT FORMS USED FOR DOCUMENTATION
- INITIAL ASSESSMENT FORMS
- FREQUENT OR ONGOING ASSESSMENT FORMS
- FOCUSED OR SPECIALTY AREA ASSESSMENT FORM
it can be exposed/implied. A patient’s agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences
INFORMED CONSENT
TYPES OF INFORMED CONSENT
Verbal
Implied
Written
mutual decision making between both professional and patient over treatment option that the patient wishes to receive or not to receive
Purpose of informed consent
- when an individual clearly states their agreement to an intervention procedure.
- should be obtained if there is any doubt of a person’s implied consent to minor procedures
Verbal Informed consent
- this is taken through participation
- not explicitly given by the individual but is
interfered from the person’s action and
inactions
Implied informed consent
must be obtained when procedures are:
* invasive/ has significant potential complications / side effects
* significant, irreversible side effects
* requires surgical, medical, invasive radiology,
oncology or endoscopy treatment
Written informed consent
process of confirming or verifying that the subjective and objective data collected are reliable or accurate
VALIDATING DATA
o excessive or insufficient eye contact
o distraction and distance
o standing
NON – VERBAL COMMUNICATION
o biased or leading questions
o rushing through the interview
o reading the questions
VERBAL COMMUNICATION
if client has hearing loss, speak slowly, face the client at all times, position yourself so that you are speaking on the side of the client that has the ear with better acuity
GERONTOLOGIC VARIATIONS IN COMMUNICATION
o communication with the use of pictures may be helpful
o it may be necessary to use an interpreter if you need to interview a client who does not speak your language
CULTURAL VARIATIONS IN COMMUNICATION
o provide the client with simple, organized information
o explain who you are along with your role and purpose
o ask simple and concise questions
o avoid becoming anxious
o do not hurry and decrease external stimuli
WHEN INTERACTION WITH AN ANXIOUS CLIENT
o approach this client in a calm, reassuring in control manner
o allow client to ventilate feelings
o if the client is out of control, do not argue or touch the client
o obtain help from other health professionals as needed
o avoid arguing and facilitate personal space
o never allow the client to position himself between you and
the door
WHEN INTERACTING WITH AN ANGRY CLIENT
o express interest in understanding of the client & responding a neutral manner
o do not try to communicate in an upbeat, encouraging manner
INTERACTING WITH DEPRESSED CLIENT
o if you are not sure that you are being manipulated, obtain objective opinion from another colleague or health care
professional
o provide a structure and set limits
o differentiate manipulation and a reasonable request
INTERACTING WITH A MANIPULATIVE CLIENT
o set firm limits on overt sexual client behavior and avoid responding to subtle seductive behavior
o if the overt sexuality continues, do not interact without business
INTERACTING WITH A SEDUCTIVE CLIENT
o ask simple questions in non-judgmental manner
o allow time for ventilation of elements and feelings as needed
o make referrals as appropriate. If you do not feel comfortable in discussing sensitive topics
DISCUSSING SENSITIVE ISSUES (SEXUALITY, DYING, AND SPIRITUALITY)
STEPS ON DATA ANALYSIS
- identify strengths and abnormal data
- cluster data
- draw inferences
- propose possible nursing diagnosis
- check for defining characteristics
- confirm or rule out diagnosis
- document conclusions
TYPES OF NURSING DIAGNOSIS
- actual/problem focused nursing diagnosis
- wellness/health promotion nursing diagnosis
- risk/possible nursing diagnosis
- syndrome diagnosis
- collaborative problems and referrals
MARJOY GORDON’S FUNCTIONAL HEALTH PATTERN
NUTRITIONAL – METABOLIC PATTERN
ELIMINATION PATTERN
ACTIVITY – EXERCISE PATTERN
SLEEP – REST PATTERN
COGNITIVE – PERCEPTUAL PATTERN
SELF – PERCEPTION PATTERN
ROLE – RELATIONSHIP PATTERN
SEXUALITY – REPRODUCTIVE PATTERN
COPING – STRESS MANAGEMENT PATTERN
VALUES – BELIEF PATTERN
o determines how the client perceives and maintains his or her health
o assess compliance with current and past nursing and medical recommendation
HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN
o determine the client’s dietary habits and intake and metabolic needs
o assess the conditions of hair, skin, nails, teeth, and mucous membranes
NUTRITIONAL – METABOLIC PATTERN
o determine the adequacy and function of the client’s bowl and bladder and urinary routines and habits for elimination
o assess for any urinary and bowel problems
ELIMINATION PATTERN
o determine the client’s activities of daily living, occupation, leisure and exercise pattern
ACTIVITY – EXERCISE PATTERN
o determine the client’s perception of the quality of his/her sleep and relaxation and energy levels
o assess methods used to promote relaxation and sleep
SLEEP – REST PATTERN
o determine the functionality status of the five senses
o assess devices and methods used to assist the client with deficits in any of the sensory organs
COGNITIVE – PERCEPTUAL PATTERN
o determine how the client perceives his/her situation, classify health goals
SELF – PERCEPTION PATTERN
o determine 2 aspects: 1. Communication, what language does the client use and understand; 2. Relationship, is the client living alone or with family, support system and access to family life such as role discipline, finances, communication pattern, parenting and marital difficulties
ROLE – RELATIONSHIP PATTERN
o determine the client’s fulfillment of sexual needs and perceived level of satisfaction
o assess reproductive pattern, developmental level and perceived problems which relates sexual activities, relationship and self-concept
SEXUALITY – REPRODUCTIVE PATTERN
o determine the client’s ability to understand, communicate, remember and able to make decisions, changes and obstacles that the client experiences that could affect his or her decisions and how the client use coping mechanisms in times of crisis/stress
COPING – STRESS MANAGEMENT PATTERN
