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Health Assessment Lecture > Collecting Subjective Data > Flashcards

Collecting Subjective Data Flashcards

1
Q

What is communication?

A

process of sharing and sending info and meaning

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2
Q

Communication can be done ___________ and _______________

A

Verbal and non-verbal

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3
Q

What are the different types of Nonverbal Communication

A
  1. Vocal ques 2. Action ques or Kinetics 3. Object Ques 4. Personal Space 5. Proxemics 6. Touch
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4
Q

Type of non verbal communication that focuses signs we get from the quality, flections, tone, intensity and speed of the person talking

A

Vocal que

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5
Q

Type of non verbal communication that focuses on a persons body movement that reflects feeling, mood, underlying physiologic and psychologic problems

A

Action Ques or Kinetics

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6
Q

Type of non verbal communication that focuses on how a person grooms and the clothes worn

A

Object Ques

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7
Q

Type of non verbal communication that focuses distance you keep yourself from other people

A

Personal Space

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8
Q

Proxemics

  1. Public Space :
  2. Social Consultative Space :
  3. Personal Distance :
  4. Intimate :
A
  1. Public Space : 12ft or more
  2. Social Consultative Space : 4 -12ft
  3. Personal Distance : 18 in to 4 ft
  4. Intimate : 0 to 18in
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9
Q

This is a type of non verbal communication that may have different interpretations depending on ones culture. It also helps gain patient trust and obtain accurate health history

A

Touch

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10
Q

2 types of Data

A

Subjective and Objective

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11
Q

2 Sources of data

A

Primary and Secondary Data

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12
Q

What are the different methods of Data Collection

A
  1. Observation 2. Interview 3. Physical Assessment
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13
Q

What is the purpose of an Interview?

A
  • gather data -establish rapport - teach patient - Health Promotion
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14
Q

What are the skills needed in an Interview?

A

Observant of Nonverbal ques and listening skills

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15
Q

How to show full attention during a interview? L.O.V.E.R.S.

A

L - ean Forward
O - pen Stance
V - erbal Output
E - ye Contact
R - elaxed Mode
S - it at 45 degree angle

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16
Q

What are the 2 types of questions?

A

Open and close ended questions

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17
Q

What are the 2 types of Interviews?

A
  1. Directive
  2. Nondirective
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18
Q

A type of interview:

Nurse has control on the questions and it requires less time.

A

Directive

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19
Q

Guide questions to lead interview

A
  • Go wherever the feeling is greatest or more intense
  • Pay attention to what patient has set aside to mention last
  • The doctor only picks up from what the patient has already brought open
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20
Q

A type of interview:

  • Patient has control over the questions
  • Takes a long time
A

Non-directive

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21
Q

what are the Phases of an interview?

A
  1. Introductory Phase 2. Working Phase 3. Termination Phase
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22
Q

Self introduction and the purpose of the interview is stated on this phase

A

Introductory Phase

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23
Q

Data collection is done and is the longest phase

A

Working Phase

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24
Q

Summarization of everthing that the patient is done and follow up plans for the pateint is being explained during this phase

A

Termination Phase

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25
Q

15 Interview Techniques

A
  1. Active Listening Skill
  2. Affirmation or Facilitation
  3. Silence
  4. Clarifying
  5. Restating
  6. Broad or General Openings
  7. Reflection
  8. Informing
  9. Redirecting
  10. Focusing
  11. Sharing Perceptions
  12. Sequencing Events
  13. Suggesting
  14. Presenting Reality
  15. Summerizing
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26
Q

Interview Technique:

  • give full attention
    -maintain eye contact
A

Active Listening Skill

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27
Q

Interview Technique:

  • Acknowledge patients response
  • use of nonverbal gestures like nodding, leaning forward or sitting up
A

Affirmation or Facilitation

28
Q

Interview Technique:

  • allows patient to collect thoughts before responding
  • prevents hasty responses
  • gives nurse more time to think
A

Silence

29
Q

Interview Technique:

  • rephrasing what patient said and patiently wait for clarification
  • it is done when nurse is unsure
A

Clarifying

30
Q

Interview Technique:

  • shows patient that your listening
  • acknowledges patient’s feelings
  • encourages further discussion
  • helps clarify and validate what patient said
  • helps identify teaching needs of patient
A

Restating

31
Q

Interview Technique:

  • when nurse wants to hear what is important from the patient
A

Broad or General Openings

32
Q

Interview Technique:

  • acknowledges patient’s feelings, encouraging further discussion
  • patient expressses then nurse echoes it back via questions
A

Reflection

33
Q

Interview Technique:

  • give info that allows patient to be involved in his or her health care decisions
A

Informing

34
Q

Interview Technique:

  • helps keep communication with patient goal oriented
A

Redirecting

35
Q

Interview Technique:

  • allows you to hone in on one specific area
  • encourages further discussion
A

Focusing

36
Q

Interview Technique:

  • nurse gives interpretation of what patient said
  • done in order to clarify things and prevent misunderstandings
A

Sharing perceptions

37
Q

Interview Technique:

  • may need to help patient place events in order
  • start at beginning until you reach a conclusion
A

Sequencing Events

38
Q

Interview Technique:

  • present alternative ideas
  • helpful when patient has difficulty verbalizing his or her feelings
A

Suggesting

39
Q

Interview Technique:

  • help patient reexamine what has already been said and be more realistic
  • done when patient is exaggerating
A

Presenting reality

40
Q

Interview Technique:

  • Concludes major section of interview
  • allows patient to clarify any misconceptions of the nurse
A

Summarizing

41
Q

How Interview Fails:

  • doesn’t let patient describe with on words
  • leads patient to say certian terms
A

Leading

42
Q

How Interview Fails:

  • overwhelms patient
  • confuses patient
A

Asking more than one question

43
Q

How Interview Fails:

  • doesnt give patient time to think
A

Not allowing enough response time

44
Q

How Interview Fails:

  • using medical terms when talking with patient
A

Using Medical Jargon

45
Q

How Interview Fails:

  • leads to inaccurate interpretations and incorrect conclusions
A

Assuming

46
Q

How Interview Fails:

  • punching patient or neglecting patient for verbally attacking you
A

Taking patient’s response personally

47
Q

How Interview Fails:

  • telling patient false information
A

False Reassurance

48
Q

How Interview Fails:

  • forcing a patient to answer your questions making patient uncomfortable
A

Persistant Questioning

49
Q

How Interview Fails:
- nurse changes subject when conversation is making him or her uncomfortable

A

Changing of Subject

50
Q

How Interview Fails:
- drawing conclusions before all facts have been gathered

A

Jumping to conclusions

51
Q

Provides holistic, qualitative picture of the
patient.

A

HEALTH HISTORY

52
Q

PURPOSES of Health History

A
  • Provide subjective database.
  • Identify patient strengths
  • Identify health problems
  • Identify supports
  • Identify teaching, discharge, and
    referral needs.
53
Q

What does the Biographical Data include

A

✓ Name
✓ Address and Phone Number
✓ Age and birth date
✓ Birthplace
✓ Gender
✓ Marital Status
✓ Race
✓ Religion
✓ Educational Level
✓ Occupation
✓ Contact Person

54
Q

Reason for Patient to Seek Healthcare

A

❖ Patient’s perspective on the problem.
❖ Brief and spontaneous statement in the
patient’s own words.
❖ The chief complaint is not a diagnostic
statement. Avoid translating it into medical
terms.

55
Q

Current Health Status

A

▪ Usual health status
▪ Any major health problems
▪ Usual patterns of healthcare
▪ Health concerns

56
Q

Method for collecting current health status of Patient PQRST

A
  • Precipitating/ Palliative Factors
  • Quality / Quantity
  • Region / Radiation / Related Symptoms
  • Severity
  • Timing
57
Q

Identify what is being described PQRST
▪ What were you doing when the problem
started?
▪ Does anything make it better, such as
medications, or certain positions?
▪ Does anything make it worse, such as
movement or breathing?

A

Precipitating/ Palliative Factors

58
Q

Identify what is being described PQRST
▪ Can you describe the symptom?
▪ What does it feel like, look like, or sound
like?
▪ How often are you experiencing it?
▪ To what degree does this problem affect
your ability to perform your ADL?

A

Quality / Quantity

59
Q

Identify what is being described PQRST
▪ Can you point where the problem is?
▪ Does it occur or spread anywhere else?
▪ Do you have any other symptoms?

A

Region / Radiation / Related Symptoms

60
Q

Identify what is being described PQRST
▪ Is the symptom, mild, moderate, or severe?
▪ Grade it on a scale of 0 to 10.

A

Severity

61
Q

Identify what is being described PQRST
▪ When did the symptom start?
▪ How often does it occur?
▪ How long does it last?

A

Timing

62
Q

What is being described?

✓ Identifies health factors from the past that
have a direct relationship to patient’s current
health status.
✓ Identifies any chronic preexisting health
problems.

A

Past Health History

63
Q

Past Health History includes what?

A

▪ Childhood illnesses
▪ Hospitalizations
▪ Surgeries
▪ Serious injuries
▪ Serious/Chronic illness
▪ Immunizations
▪ Allergies
▪ Medications
▪ Recent travel

64
Q

History of Present Illness what info to get?

A

Well person - short statement about general
state of health.

Ill person - chronological record of the
reason for seeking care, from the time the
symptom first started until now.

65
Q

Provides clues to genetically linked or
familial diseases that may be risk factors for
the patient.

A

Family History

66
Q

Focuses on health promotion, protective
patterns, and roles and relationships.

A

Psychosocial Profile

Health Assessment Lecture (17 decks)

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