Chapter 2 Collecting Subjective Data: The Interview and Health History Flashcards
What are the two focuses of interviewing a pt when collecting subjective data?
To establish a rapport and trusting relationship that will elicit accurate and meaningful information.
Obtaining information on the clients developmental, psychological, physiological, sociocultural, and spiritual statuses to determine changes that can be treated with nursing and collaborative interventions or strengths that can be enhance through nurse-pt collaboration.
What is the pre-introductory phase of the pt interview?
The nurse reviews the medical record prior to meeting with the pt. This can help provide information that with assist in conducting the interview.
What is the introductory phase of the pt interview?
After introductions, there is an explanation of the purpose of the interview, discussion of types of questions that are asked, and reason for documentation, and assures confidentiality. Provide comfortable and private environment. Develop rapport with pt by using appropriate verbal and non verbal skills
What is the working phase of the pt interview?
The nurse will elicit information from the pt about the pt’s biographic info, reason for seeking care, hx of present health concern, PMH, family hx, review body systems for current health problems, lifestyle and health practices, and developmental level. The nurse pays attention to cues and uses critical thinking skills to interpret and validate data received from pt.
The nurse and pt collaborate to id the pt’s problems and goals.
What is the summary and closing phase of the pt interview?
The nurse summarizes the info obtained and validates problems and goals with the pt. The nurse id’s and discusses possible plans to resolve the problem (nursing dx and collaborative problems) with the pt.
The nurse also makes sure that all of the pt’s concerns and questions have been addressed.
What are the types of non verbal communication?
Appearance, demeanor, facial expression, attitude, silence, listening
What are the types of non verbal communication to avoid
Excessive or insufficient eye contact, distraction and distance (interview ~- ft from pt), standing (avoid standing when pt is seated, try to be on same level as pt).
What are the types of verbal communication?
open-ended questions (used to obtain significant info), closed-ended questions (used to obtain fact or specific information), laundry list (helps to obtain specific answers and avoids pt providing a perceived or expected answer), rephrasing (helps to clarify what the pt stated, also allows for reflection of what was stated), well placed phrases (responses from the nurse during interview to relay to the pt the nurse is listening to them) , inferring information (used to obtain more info by expanding upon the info the pt provides from observations of pt during the interview)providing information (giving thoroughly info when questions arise).
What types of verbal communication should be avoided?
Biased or leading questions (may cause pt to provide answers that may not be true).
Rushing through the interview (
What is COLDSPA ?
It is part of the assessment regarding the pt’s hx of present illness.
Character: How does it feel, look, smell, sound, etc.?
Onset: When did it begin, is it better, worse, or the same, since it began?
Location: Where is it? Does it radiate?
Duration: How long does it last? Does it recur?
Severity: How bad is it on a sale of 1 (barely noticeable ) to 10 ( worst pain).
Pattern: What makes it better? What makes it worse?
Associated factors: What other symptoms do you have with it?
Will you be able to continue doing your work or other activities (leisure or exercise)?
