COLLECTING DATA Flashcards
– process of gathering
information about a client’s health
status
DATA COLLECTION
in DATA COLLECTION, It must be both _______ and ______
to prevent the omission of significant data and reflect a client’s changing health status.
SYSTEMATIC & CONTINUOUS
2 TYPES OF DATA:
SUBJECTIVE DATA & OBJECTIVE DATA
Symptoms or covert data
Includes client’s:
* Sensations
* Feelings
* Values
* Beliefs
* Attitudes
* Perception of personal health
status and life situation
EXAMPLES:
Pain, itching, worry, DOB, fear
SUBJECTIVE DATA
Signs or overt data
Detectable by an observer (seen, heard, felt, smelled)
Obtained by observation or
physical examination
EXAMPLES:
Skin discoloration, vital signs
reading, slurred speech, crackles,
cyanosis
OBJECTIVE DATA
2 SOURCES OF DATA:
PRIMARY & SECONDARY
Best source of data unless the
client is too ill, young, or
confused to communicate clearly.
CLIENT
Important source of data for a
client who is very young, too ill,
unconscious, or confused.
FAMILY MEMBERS / SUPPORT PEOPLE
Include information documented by
various health care professionals.
Types of client records: medical
records, records of therapies,
laboratory records
CLIENT RECORDS
Provide pertinent health
information and allows easy
monitoring among the healthcare
team
Laboratory and
diagnostic results
Sharing of information among
professionals is especially
important to ensure continuity
of care and a potential source
of information about a
client’s health.
HEALTH CARE PROFESSIONALS
Review of nursing and related
literature can provide
additional information for the
database.
RELEVANT LITERATURE
3 METHODS OD DATA COLLECTION
- OBSERVING
- INTERVIEWING
- EXAMINING
Gathering data by the use of senses.
Involves distinguishing data in a
meaningful manner
OBSERVING
A planned communication or a
conversation
Purpose:
* Get or give information
* Identify problems of mutual
concern
* Evaluate change
* Teach
* Provide support
* Provide counseling or therapy
INTERVIEWING
Highly structured and
elicits specific information.
The nurse establishes the
purpose of the interview
and controls the interview.
Uses closed questions
DIRECTIVE INTERVIEW
Rapport building interview.
The client is allowed to control the purpose, subject matter, and
pacing.
Uses open-ended questions
NON DIRECTIVE INTERVIEW
Restrictive and generally require only “yes” or “no” or short factual
answers that provide specific information.
Often begin with “when,” “where,” “who,” “what,” “do (did, does),” or
“is (are, was)
CLOSED QUESTIONS
Invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.
The open-ended question is useful at the beginning of an interview or to change topics and to elicit attitudes.
May begin with “what” or “how”
OPEN - ENDED QUESTIONS
An open ended question that the client can answer without direction or pressure from the nurse.
NEUTRAL QUESTION
A closed question which directs the client’s answer.
Creates problems if the client, in an effort to please the nurse, gives inaccurate responses.
LEADING QUESTION
that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
SYSTEMIC DATA COLLECTION METHOD
2 APPROACHES IN PHYSICAL ASSESSMENT/ EXAMINATION
- CEPHALOCAUDAL OR HEAD TO TOE APPROACH
- BODY SYSTEMS
Intimacy VS Isolation
YOUNG ADULT
