Collecting Subjective Data: The Interview and Health History Flashcards
The nursing interview has four basic phases:
pre-introductory,
introductory,
working,
summary/closing phases
phase: The nurse reviews the medical record before meeting with the client
pre-introductory
phase: After introducing herself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential
introductory
phase: The nurse makes sure that the client is comfortable (physically and emotionally) and
has privacy. Developing rapport
depends heavily on verbal and nonverbal communication on the part of the nurse
introductory
During this phase, the nurse elicits the client’s comments about major biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems (ROS) for current health problems, lifestyle and health practices, and developmental level.
working phase
the nurse summarizes information obtained during the working phase and validates problems and goals with the client. She also identifies and discusses possible plans to resolve the problem (client
concerns and collaborative problems) with the client. Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions.
summary and closing phase
The client interview involves two types of communication—
nonverbal and verbal
First take care to ensure that your ?? is professional. The client is expecting to see a health professional; therefore, you should look the part
appearance
When you enter a room to interview a client, display poise. Focus on the client and the upcoming interview and assessment. Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath. It is best to maintain a professional
distance.
demeanor
often an overlooked aspect of communication. It often shows what you are truly thinking (regardless of what you are saying), monitor them closely
facial expressions
It means using the right expression at the right time.
displaying neutral expression
One of the most important nonverbal skills to develop as a health care professional is a ???. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices.
nonjudgmental attitude
Five “A”s of Behavior Change:
Ask, Advise, Assess, Assist, and Arrange
allow you and the client to reflect and organize thoughts, which facilitate more accurate reporting and data collection.
silence
most important skill to learn and develop fully in order to collect
complete and valid data from your client.
listening
are used to elicit the client’s feelings and perceptions. They typically begin with the words “how” or “what.”
Open-ended questions
Use ??? to obtain facts and to focus on specific information. The client can respond with one or two words.
closed-ended questions
typically begin with the words “when” or “did.”
Closed-ended questions
approach: Another way to ask questions is to provide the client with a list of words to choose
from in describing symptoms, conditions, or feelings.
laundry list
??? information the client has provided is an effective way to communicate during the interview. 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
The nurse can encourage client verbalization by using ??.
well-placed phrases
??? information from what the client tells you and what you observe in the client’s behavior may elicit more data or verify existing data.
Inferring information
Another important thing to do throughout the interview is to provide the client with
??? as questions and concerns arise.
information
Three variations in communication must be considered as you interview clients:
gerontologic, cultural, and emotional.
When interviewing an older client, you must first assess ???
hearing acuity
Do not try to communicate in an upbeat, encouraging manner. This will not help the ??? client.
depressed
is an excellent way to begin the assessment process because it provides the foundation for clinical judgments in identifying nursing problems, where to focus, and areas where a more detailed physical examination may be needed.
health history
are used to identify clients’ strengths and limitations in lifestyle and health status
Health history data
usually 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?”
reason(s) for seeking health care
This section of the health history takes into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern
history of present health concern
COLDSPA
CHARACTER
ONSET
LOCATION
DURATION
SEVERITY
PATTERN
ASSOCIATED FACTORS
This portion of the health history focuses on questions related to the client’s personal history, from the earliest beginnings to the present
personal health history
As researchers discover an increasing number of health problems that seem to run in
families and that are genetically based, this assumes greater importance.
family health history
Drawing a helps to organize and illustrate the client’s family history
genogram
“A/W”
(alive and well)
each body system is addressed and the client is asked specific questions to elicit further details of current health problems or problems from the recent past that may still affect the client or that are recurring.
review of systems
This is a very important section of the health history because it deals with the client’s human responses, which 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 and 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
Ask the client to recall what consists of an average 24-hour intake with emphasis on what foods are eaten and in what amounts. Also ask about snacks, fluid intake, and other substances consumed.
nutrition and weight management
assess how active the client is during an average week either at work or at home. Inquire about regular exercise. Some clients believe that if they do heavy physical work at their job, they do not need additional exercise
activity level and exercise
Inquire whether the client feels they are getting enough sleep and rest. Questions should focus on specific sleep patterns, such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems in sleeping
sleep and rest
Sleepiness Scale
Stanford
scale rating of stanford sleepiness scale
1-7
The complete health history is performed to collect as much subjective data about a client as possible. It consists of eight sections:
biographical data,
reasons for seeking health care,
history of present health concern,
personal health history,
family health history,
ROS for current health problems,
lifestyle and health practices,
developmental level.
