CHAP 2 Flashcards
Subjective
data provide clues to:
physiological, psychological, and sociologic
problems.
The subjective data is obtained through
interviewing
2 focuses of nursing interview
- establish rapport & rltship
gain info on client - developmental, psychological status
4 basic phases of an interview in nursing:
preintroductory
introductory
working
summary
in this phase, the nurse reviews the medical record before meeting with the client
Knowing some of the client’s already documented biographical information
Preintroductory phase
during the introductory phase, the nurse explains these:
- discuss the of questions
- explain reason for notes
- assure confidential info to the client
the guidelines that ensure confidentiality of client info
Health Insurance Portability and Accountability Act (HIPAA)
conducting an interview should be at what level
eye level with client
these are essential to promote full disclosure of information
develop trust and rapport
Developing rapport
depends heavily on
verbal and nonverbal communication
During this phase, the nurse elicits the client’s comments about major biographical
data
Working phase
during this phase, the nurse summarizes information obtained during
the working phase and validates problems and goals with the client
Summary & closing phase
in this phase, the nurse identifies and discusses possible plans to resolve the problem
summary and closing phase
The client interview involves two types of communication
Nonverbal and verbal
Your appearance, demeanor, posture, facial expressions, and attitude strongly influence
how the client perceives the questions you ask belongs to what type of communication
Nonverbal communication
Actions that must be followed during a nurisng interview of nonverbal actions
Appearance
Demeanor
Facial expression
Attitude
Silence
Listening
The client is expecting
to see a health professional; therefore, you should look the part. Wear comfortable,
neat clothes and a laboratory coat or a uniform. What type of nonverbal component is this?
Appearance
in nonverbal communication your ___ should be professional
Demeanor
not being overwhelmingly friendly/touchy is under
Demeanor
Greeting the client calmly, by name and not
with references such as honey, sweetie, or sugar is under what type of nonverbal communication
Demeanor
When you enter a room to interview a
client, display what?
Poise
an overlooked aspect of communication. it often shows what you are truly thinking
Facial expression
No matter what you think about a client or what kind
of day you are having, keep your expression
neutral and friendly
appear shocked, disgusted, or surprised at what you are told is under
Attitude
One of the most important nonverbal skills to develop as a health care professional
is a
Nonjudgemental attitude
allow you and the client to reflect and organize thoughts, which facilitate
more accurate reporting and data collection.
silence
is the most important skill to learn and develop fully in order to collect
complete and valid data from your client
Listening
Nonverbal communications to avoid
Excessive or Insufficient Eye contact
Distraction & distance
Standing
Verbal Communication to avoid
Biased or leading question
Rushing through interview
Reading the questions
these questions are used to elicit the client’s feelings and perceptions
Open ended questions
open ended questions begins with the words
“how” or “what”
Asking _____may help to reveal
significant data about the client’s health status.
open ended questions
these questions are asked to obtain facts and to focus on specific information
close ended questions
these questions are useful in keeping the interview on course
close ended questions
Closed-ended questions typically begin
with the words
“when or did”
used to clarify or obtain more accurate information
Close ended questions
this approach
helps you to obtain specific answers and reduces the likelihood of the client
perceiving or providing an expected answer.
laundry list
these type of questions are what? “Is the pain severe, dull,
sharp, mild, cutting, or piercing?” “Does the pain occur once every year, day,
month, or hour?” Repeat choices as necessary.
Laundry list
This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
Rephrasing
these words can encourage client verbalization
Well-placed phrases
“uh-huh,” “yes,” or “I agree” are what types of words
Well placed phrases
getting information from what the client tells you and what you observe in the
client’s behavior may elicit more data or verify existing data is what type of action
Inferring
Examples of verbal communication
Open & close ended
Laundry list
Rephrasing
Well-placed phrases
inferring
Providing information
include information that identifies the client, such as
name, address, phone number, gender, and who provided the information—the
client or significant others
Biographical data
This category includes two questions: “What is your major health problem or
concern at this time?” and “How do you feel about having to seek health care?”
Reasons for seeking health care
Three variations in communication must be considered as you interview clients
gerontologic, cultural and emotional
age effects are under what variation of interviewing
Gerontologic variations
used to identify clients’ strengths and limitations in
lifestyle and health status
Health history data
Religious or spiritual practices
Educational level
Occupation are what type of data
Biographical data
Meaning of COLDSPA
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
(How does it feel, look, smell, sound, etc.? is what type of question
Character
when did it begin? is it worse than before? what statement tdoes this belong
Onset
what makes it better? unsay maka lala ani? is what type of question
Pattern
what other sympomts do u have? can u work with having this?
Associated factors
Nursing health history format (client care plan)
Biographical data
History of present health (COLDSPA)
Past health history
Family Health history
Lifestyle and Health practice
Developmental Level
PQRST meaning
Provocative
Quality
Radiates
Severity
Timing
in pqrst what does this question stand for “What provokes the pain or relieves it?
Provocative
is the pain localized? or ga spread? what type of analysis is this from PQRST stand for?
Radiates
Ask the client about
any childhood illnesses and immunizations to date is what type of data
Personal health history
the questions elicit data about the client’s health history related to their
strengths and weaknesses
Past health or personal history
include nutritional habits, activity and exercise
patterns, sleep and rest patterns, self-concept and self-care activities, social and
community activities, relationships, values and beliefs system, education and work,
stress level and coping style, and environment.
Lifestyle & health practices profile
This information is necessary to elicit an overview of how the client sees their usual
pattern of daily activity
Description of typical day
These questions
uncover food habits that are health promoting as well as those that are less desirable
Nutrition and weight management
sexual responsibility, basic hygiene practices, regularity of health
care checkups (i.e., dental, visual, medical), breast/testicular self-examination, and
accident prevention and hazard protection (e.g., seat belts, smoke alarms, and
sunscreen). are under what data
self concept and self care responsibilities
