Collecting Subjective Data Flashcards
What is communication?
process of sharing and sending info and meaning
Communication can be done ___________ and _______________
Verbal and non-verbal
What are the different types of Nonverbal Communication
- Vocal ques 2. Action ques or Kinetics 3. Object Ques 4. Personal Space 5. Proxemics 6. Touch
Type of non verbal communication that focuses signs we get from the quality, flections, tone, intensity and speed of the person talking
Vocal que
Type of non verbal communication that focuses on a persons body movement that reflects feeling, mood, underlying physiologic and psychologic problems
Action Ques or Kinetics
Type of non verbal communication that focuses on how a person grooms and the clothes worn
Object Ques
Type of non verbal communication that focuses distance you keep yourself from other people
Personal Space
Proxemics
- Public Space :
- Social Consultative Space :
- Personal Distance :
- Intimate :
- Public Space : 12ft or more
- Social Consultative Space : 4 -12ft
- Personal Distance : 18 in to 4 ft
- Intimate : 0 to 18in
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
Touch
2 types of Data
Subjective and Objective
2 Sources of data
Primary and Secondary Data
What are the different methods of Data Collection
- Observation 2. Interview 3. Physical Assessment
What is the purpose of an Interview?
- gather data -establish rapport - teach patient - Health Promotion
What are the skills needed in an Interview?
Observant of Nonverbal ques and listening skills
How to show full attention during a interview? L.O.V.E.R.S.
L - ean Forward
O - pen Stance
V - erbal Output
E - ye Contact
R - elaxed Mode
S - it at 45 degree angle
What are the 2 types of questions?
Open and close ended questions
What are the 2 types of Interviews?
- Directive
- Nondirective
A type of interview:
Nurse has control on the questions and it requires less time.
Directive
Guide questions to lead interview
- 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
A type of interview:
- Patient has control over the questions
- Takes a long time
Non-directive
what are the Phases of an interview?
- Introductory Phase 2. Working Phase 3. Termination Phase
Self introduction and the purpose of the interview is stated on this phase
Introductory Phase
Data collection is done and is the longest phase
Working Phase
Summarization of everthing that the patient is done and follow up plans for the pateint is being explained during this phase
Termination Phase
15 Interview Techniques
- Active Listening Skill
- Affirmation or Facilitation
- Silence
- Clarifying
- Restating
- Broad or General Openings
- Reflection
- Informing
- Redirecting
- Focusing
- Sharing Perceptions
- Sequencing Events
- Suggesting
- Presenting Reality
- Summerizing
Interview Technique:
- give full attention
-maintain eye contact
Active Listening Skill
Interview Technique:
- Acknowledge patients response
- use of nonverbal gestures like nodding, leaning forward or sitting up
Affirmation or Facilitation
Interview Technique:
- allows patient to collect thoughts before responding
- prevents hasty responses
- gives nurse more time to think
Silence
Interview Technique:
- rephrasing what patient said and patiently wait for clarification
- it is done when nurse is unsure
Clarifying
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
Restating
Interview Technique:
- when nurse wants to hear what is important from the patient
Broad or General Openings
Interview Technique:
- acknowledges patient’s feelings, encouraging further discussion
- patient expressses then nurse echoes it back via questions
Reflection
Interview Technique:
- give info that allows patient to be involved in his or her health care decisions
Informing
Interview Technique:
- helps keep communication with patient goal oriented
Redirecting
Interview Technique:
- allows you to hone in on one specific area
- encourages further discussion
Focusing
Interview Technique:
- nurse gives interpretation of what patient said
- done in order to clarify things and prevent misunderstandings
Sharing perceptions
Interview Technique:
- may need to help patient place events in order
- start at beginning until you reach a conclusion
Sequencing Events
Interview Technique:
- present alternative ideas
- helpful when patient has difficulty verbalizing his or her feelings
Suggesting
Interview Technique:
- help patient reexamine what has already been said and be more realistic
- done when patient is exaggerating
Presenting reality
Interview Technique:
- Concludes major section of interview
- allows patient to clarify any misconceptions of the nurse
Summarizing
How Interview Fails:
- doesn’t let patient describe with on words
- leads patient to say certian terms
Leading
How Interview Fails:
- overwhelms patient
- confuses patient
Asking more than one question
How Interview Fails:
- doesnt give patient time to think
Not allowing enough response time
How Interview Fails:
- using medical terms when talking with patient
Using Medical Jargon
How Interview Fails:
- leads to inaccurate interpretations and incorrect conclusions
Assuming
How Interview Fails:
- punching patient or neglecting patient for verbally attacking you
Taking patient’s response personally
How Interview Fails:
- telling patient false information
False Reassurance
How Interview Fails:
- forcing a patient to answer your questions making patient uncomfortable
Persistant Questioning
How Interview Fails:
- nurse changes subject when conversation is making him or her uncomfortable
Changing of Subject
How Interview Fails:
- drawing conclusions before all facts have been gathered
Jumping to conclusions
Provides holistic, qualitative picture of the
patient.
HEALTH HISTORY
PURPOSES of Health History
- Provide subjective database.
- Identify patient strengths
- Identify health problems
- Identify supports
- Identify teaching, discharge, and
referral needs.
What does the Biographical Data include
✓ Name
✓ Address and Phone Number
✓ Age and birth date
✓ Birthplace
✓ Gender
✓ Marital Status
✓ Race
✓ Religion
✓ Educational Level
✓ Occupation
✓ Contact Person
Reason for Patient to Seek Healthcare
❖ 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.
Current Health Status
▪ Usual health status
▪ Any major health problems
▪ Usual patterns of healthcare
▪ Health concerns
Method for collecting current health status of Patient PQRST
- Precipitating/ Palliative Factors
- Quality / Quantity
- Region / Radiation / Related Symptoms
- Severity
- Timing
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?
Precipitating/ Palliative Factors
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?
Quality / Quantity
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?
Region / Radiation / Related Symptoms
Identify what is being described PQRST
▪ Is the symptom, mild, moderate, or severe?
▪ Grade it on a scale of 0 to 10.
Severity
Identify what is being described PQRST
▪ When did the symptom start?
▪ How often does it occur?
▪ How long does it last?
Timing
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.
Past Health History
Past Health History includes what?
▪ Childhood illnesses
▪ Hospitalizations
▪ Surgeries
▪ Serious injuries
▪ Serious/Chronic illness
▪ Immunizations
▪ Allergies
▪ Medications
▪ Recent travel
History of Present Illness what info to get?
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.
Provides clues to genetically linked or
familial diseases that may be risk factors for
the patient.
Family History
Focuses on health promotion, protective
patterns, and roles and relationships.
Psychosocial Profile
