COLLECTING SUBJECTIVE DATA: The Interview and Health History Flashcards
it is the integral part of interviewing the client to obtain a nursing health history
collecting subjective data
examples of collecting subjective data:
- sensation or symptoms
- feelings
- perception
- desires
- preferences
- beliefs
- ideas
- values
- personal information
it provides clues for possible problems and provides the nurse with information that may reveal a client’s risk.
subjective data
establishing rapport and a trusting relationship with the elicit, concrete and meaningful information
interviewing
it is obtained through interviewing
information
it is the gathering of information on the client’s developmental, psychological, physiologic, socio-cultural, and spiritual status to identify deviations that can be treated or strength that can be enhanced
interviewing
what are the phases of the interview?
- pre-introductory phase
- working phase
- summary or closing phase
- it is the first time meeting with a client
- It is the necessary phase where the nurse
must develop trust and rapport which can begin by conveying a sense of priority and
interest to the client
introductory phase
During this phase the nurse elicits the client’s
comments about major biographic data,
reasons for seeking care, history of present
health concern, past health history, family
history, review of body systems for current
health problems, lifestyle and health
practices, and developmental level.
working phase
summarization of the
gathered information, and validation of the problem and goals of the client
summary or closing phase
in this phase, the nurse reviews the medical record of the patient
pre-introductory phase
identify the type of special consideration during the interview:
- assess hearing activity
- do not yell, speak slowly
- position yourself on the side with better hearing activity
- The nurse may position the self in front to allow the client to read lips to better understand
- remember that older clients may feel vulnerable and scared
- speak clearly and use straightforward language
- show respect
gerontologic variations in communication
identify the type of special considerations during the interview:
- reluctance to relieve personal information
- variation in ability to receive information
- variation meaning conveyed by language
- variation use and meaning nonverbal communication
- variation in past, present, and future orientation
- variation disease or illness perception
- variation the family’s role
cultural variations of communication
identify the type of special consideration during the interview:
- clients may be anxious or scared
- clients may be depressed due to life events
- clients may be sensitive to some issues
emotional variation in communication
it is the excellent way to begin the assessment process
health history guidelines
it contains information that identifies the client. (Ex. name, address, and phone number)
biographical data
it is known as client’s chief complaint
reasons for seeing health care
what is the meaning of “CC”?
chief complaint
what do we aim to determine?
- what brought the client to seek health care
- what are the feelings of the client about seeking health care
history of present health concerns:
- problem at birth (cleft palate)
- childhood illness (measles, mumps)
- immunizations to date (hepa B vaccine)
- adult illness, surgeries, accidents, prolonged pain or pain patterns, allergies, physical disabilities
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encourage the client to explain health problem or symptom focusing on set progression and duration
- signs and symptoms and related problems
- what the client perceives as causing the problem or symptoms
- what makes the problem worse
- what makes the problem better
- which treatment has been tried
- what effect the problem as in daily life
- what is the client’s ability to provide self care
gathering comprehensive history of present concern
nemonics
NEMONICS:
what brought about the pain
precipitating factors
NEMONICS:
what the patient feels like and how does it look like?
quality/character
NEMONICS:
where do you feel the pain?
region / radiation
NEMONICS:
using rating scale (1-10)
severity
NEMONICS:
how long it last?
time / duration
NEMONICS:
how does it feel, look, smell, and sound?
character
NEMONICS:
where is it? does it radiate?
location / radiation
NEMONICS:
how long it lasts, does it recur?
duration
NEMONICS:
(alang meaning)
- Pattern
- Associated factors
- age of parents
- parents illness and longevity
- drawing genogram helps to organize and illustrate
family health history
it is the series of questions about all body systems that helps to reveal concerns as part of a comprehensive health assessment
review of systems
- when able, the patient fills out a form
- ask any symptoms related to each body system. (e. g., cough - respiratory system)
review of systems
what is the purpose of reviewing systems?
it evaluates the past and present health state of each system it may vary in sequence and format
- it may identify problem not uncovered previously in the history and provide an opportunity to indicate client strengths and liabilities
- from cephalad to caudad
ROS - subjective data
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- in addition to ROS, obtain information from the patient about health promotion practices
- begin with a general questions. (e.g., how is your appetite?)
- then progress to more detail. (e.g., have you had any nausea, allergies, or gastric reflux?)
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ROS - Subjective date
- documents not only the presence of findings but also the absence of problems of symptoms
- when arriving at the section of the interview that includes presenting situation
- explain that although the review is lengthy, it is an opportunity to double check for completeness and accuracy of past and current problems
- adopt topics to the patient and direct conversation
it is the weight of gain loss, fatigue, weakness, malaise, pain, usual activity, fever, and chills
general health state
it is the history of conditions that increase the risk of malnutrition or obesity. nausea and vomiting. Norma; daily intake, weight and weight change, noting if changes were intentional are not dehydration, dry, skin, fluid excess, with shortness of breath, or edema in the feet and legs
- diet practices to promote health
nutrition and hydration
it is the history of skin, hair, or nail disease
. rush itching pigmentation or texture change lesions sweating dry skin hair loss or change in texture brittle or thin nails and thick yellow nails
skin, hair, and nails
it is the history of high or low thyroid hormones level. headaches, syncope, dizziness, and sinus pain
head and neck
it is the poor vision or vision problem.
ex: lacoma cataracts use of contact lenses or glasses, change in vision
eyes
- history of head or brain injury
neurological
history of ear or hearing problems hearing loss
ears
history of mouth or throat cancer - cold, sore throat, nasal obstruction, nosebleeds
nose, mouth, throat
- history of emphysema, asthma, or lung cancer.
- wheezing, cough, sputum, dyspnea, last chest x-ray and result
thorax and lungs
congenital heart problems, myocardial infarction, heat surgery, heart failure, arrhythmia, and murmur
heart and neck vessels
high blood pressure, peripheral vascular disease
peripheral vascular
history of breast cancer or cystic breast condition. For adolescence, for males gynecomastia pain, tenderness …
breasts
history of colon cancer, gastrointestinal bleeding, cholelithiasis, liver failure, pancreatitis
abdominal and gastrointestinal
renal failure, polycystic kidney disease, urinary tract infection and nephrolithiasis
abdominal/urinary
history of injury and arthritis
musculoskeletal
history of undescended testicle, hernia (luslos), intesticular cancer, pain, burning, lesions, discharge, and swelling
male genitalia
a history of ovarian or uterine cancer, ovarian cyst, endometriosis, number of pregnancies and children, pain, homing, lesions .
female genitalia
history of hemorrhoids: prostate cancer
- benign prostatic hyperplasia; the urinary incontinence, burning, and itching
anus, rectum, and prostate
a history of diabetes mellitus, high or low thyroid levels, and anemia
endocrine and hematological system
what are the 3 physical exam preparation?
- preparing the clinical setting
- preparing oneself
- preparing the patient
identify the type of physical exam preparation:
- comfortable, warm room temperature, provides a warm blanket
- private area free of interruptions from others: close the door or pull the curtains
- quiet area
- adequate lighting
- firm examination table
preparing the clinical setting
identify the type of physical exam preparation:
- assess on feelings and anxieties
- achieve self confidence through practice
- prevent transmissions of infection agents
1. hand washing
2. always wear gloves
preparing oneself
what are the two preventive measures in transmissions of infectious agents?
- hand washing
- always wear gloves
identify the type of physical exam preparation:
- establish a nurse-patient relationship prior to physical examination, explain and describe to the patient what the physical exam will involve
- respect the client’s desires and requests
- ask the client to urinate before the exams
- have the patient change to exam gown
- continue to explain what procedure you are going to perform
preparing the patient
POSITIONING TECHNIQUE:
for evaluating the head, neck, chest, back, breast, axillae, heart, vital signs, and upper extremities
sitting position
POSITIONING TECHNIQUE:
allows abdominal muscles to relax and provide easy access
supine position
it prepares the client for the changes
positioning techniques
POSITIONING TECHNIQUE:
more comfortable than the supine position for client
dorsal recumbent position
POSITIONING TECHNIQUE:
it is for assessing the rectal and vaginal areas
sims position
POSITIONING TECHNIQUE:
it allows examiner to assess the posture
standing position
POSITIONING TECHNIQUE:
hips joint. back can also be assessed
prone position
POSITIONING TECHNIQUE:
- examining the rectum
- it may be embarrassing and uncomfortable
knee chest position
POSITIONING TECHNIQUE:
- to examine genitalia, reproductive tracts, and rectum
- keep the client well draped
lithotomy position
confirming or verifying information if it is correct
validating data
- it is the discrepancies between the collected subjective and objective data
- discrepancies what a client said at one time
data requiring validation
what are the methods of validation?
- rechecking data
- by asking additional question
- verify the data with another health care
- compare your objective findings with your subjective data
- it promotes the effective communication among multidisciplinary health team members
documentation of data
- documented assessment data provides a database that becomes the foundation care of client
- to identify health problems, formulate nursing diagnosis, and plan immediate and ongoing intervention
documentation of data
what are the guidelines for documentation?
- keep confidential all documented information in the client record
- document legibly or print neatly in non erasable ink
- use correct grammar and spelling
- avoid wordiness that creates redundancy
- use phrases instead of sentences to record data
- record data findings
- write entries objectively without making premature judgments or diagnosis
- include additional assessment
conclusion
diagnosis
it is the clinical judgement about individual, family, our community responses to actual and potential health problems or life processes
NANDA
it provides the basis for selection of nursing interventions to achieve outcomes for which the nurses is accountable
NANDA
STATUS OF THE NURSING DIAGNOSES:
- it is the problem presents at the time of assessment
- the presence of associated signs and symptoms
actual diagnosis
STATUS OF THE NURSING DIAGNOSES:
- preparedness to implement behaviors to improve their health condition
ex. readiness for enhanced nutrition
health promotion diagnosis
STATUS OF THE NURSING DIAGNOSES:
- problem does not exist
- presence of risk factors
risk nursing diagnosis
STATUS OF THE NURSING DIAGNOSES:
- cluster of nursing diagnosis that have similar interventions
syndrome diagnosis
what are the four status of the NURSING DIAGNOSES?
- actual diagnosis
- health promotion diagnosis
- risk nursing diagnosis
- syndrome diagnosis
what are the 8 types of positioning techniques?
- sitting position
- supine position
- dorsal recumbent position
- sims position
- standing position
- prone position
- knee chest position
- lithonomy position
COMPONENTS OF A NANDA NURSING:
- it is the problem (diagnostic label) and definition
- describes the client’s health problem or response
- it may require a specification
- it has qualifiers added to give additional meaning such as deficient, impaired, decreased, ineffective, and compromised
diagnosis
READ:
DIAGNOSIS
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- etiology (related factors and risk factors)
- defining characteristics
basic three parts statement
formulating diagnostic statements
health promotion diagnosis beginning with readiness
one part statements
READ: COMMUNICATION DURING THE INTERVIEW
the client interview involves two types of communication: nonverbal and verbal. several special techniques and certain general considerations will improve both types of communication as well as promote an effective and productive interview
your appearance, demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the question you ask. facilitate eye level contact. never overlook the importance of communication or take it for granted
nonverbal communication
it is the first take care to ensure that your ____ is professional.
- the client is expecting to see a health care professional; therefore you should look the part. wear comfortable, neat clothes, and a laboratory coat or a uniform.
- be sure that your name tag, including credentials is clearly visible
- your hair should be neat and pulled back if long
- fingernails should be short and neat and jewelry should be minimal
appearance
when you enter a room to interview a client, display poise
demeanor
- it is often an overlooked aspect of communication
- no matter what you think about a client or what kind of day you are having, we must keep neutral and friendly
facial expression
all clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and healthcare practices
attitude
this period allow you and the client to reflect and organize thoughts, which facilitate more accurate reporting and data collection
silence
it is the most important skill to learn and develop fully in order to collect complete and valid data from your client
listening
what are the 6 types of nonverbal communication?
- appearance
- demeanor
- facial expression
- attitude
- silence
- listening
this type of communication is essential to a client interview. the goal of the interview process is to elicit as much data about the clients as possible.
verbal communication
it is used to elicit the client’s feelings and perception and typically begin with the words how or what
For example, “how have you been feeling lately?”
imagine yourself interviewing an elderly nail client who is at the primary care provider’s office because of diabetic complications. He mentions casually to you, “today is the 2-month anniversary of my wife’s death from cancer. “ Failure to follow up with an open-ended questions such as “how does this makes you feel?” may result in the loss of important data that could provide clues to the client’s state of health.
open-ended questions
- to obtain facts and to focus on specific information which the client can respond with one or two words.
- it typically begins with the words “when” or “ did” (when did your headache start?)
example:
“how have you been feeling lately?”
- well, i’ve been feeling really sick to my stomach and i don’t feel like eating because of it.
“when did the nausea start?”
closed-ended questions
another way to ask questions is to provide the client with a list of words to choose from in describing symptoms conditions or feelings to obtain specific answers and reduces the likelihood of the client perceiving or providing an expected answer.
laundry list
this technique helps you to clarify information the client has stated and also enables youth and the client to reflect on what was said.
rephrasing
- if the client is in the middle of explaining a symptom or feeling and believes that you are not paying attention, you may fail to get all the necessary information.
- listen closely to the client during their description and use the phrases such as “uh-huh”, “yes”, or “I agree” to encourage them to continue
well-placed phrases
____ information from what the client tells you and what you observe in the client’s behavior may illicit more data or verify existing data.
inferring
another important thing to do throughout the interview is to provide the client with an information as questions and concern arise
providing information
7 types of verbal communication:
- open-ended questions
- closed-ended questions
- laundry list
- rephrasing
- well-placed phrases
- inferring
- providing information
READ: SPECIAL CONSIDERATIONS DURING THE INTERVIEW
three variations in communication must be considered as your interview clients: gerontologic, cultural, and emotional. This variations affect the nonverbal and verbal techniques you use during the interview
EXAMPLE: You are interviewing an 82-year-old woman and you ask her to describe how she has been feeling. She does not answer you and she looks confused. This older client may have some hearing loss. in such a case, you may need to modify the verbal technique of asking open-ended questions
normal aspects of aging do not necessarily equate with a health problem, so it is important not to approach an interview with an elderly client assuming that there is a health problem.
gerontologic variations in communication
