Collection of Subjective Data Through Interview and Health History, Collection of Objective Data Flashcards
Types of Data
Subjective
Objective
symptoms or covert data
apparent only to the person affected
Subjective Data
signs or overt data
detectable by an observer
can be measured, tested
Objective Data
To gather data using the senses
A conscious, deliberate skill
Observing
Planned communication or conversation
with a purpose
To get or give information
Interview
Nurse reviews the medical record before
meeting with the client.
If a medical record is not established, the
nurse will need to rely on interview skills
to elicit valid and reliable data from the
client and that individual’s family or
significant other
Pre-Introductory Phase
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 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
The nurse summarizes information
obtained during the working phase
and validates problems and goals with
the client.
Summary & Closing Phase
Types of Interview
Directive Interview
Non – Directive Interview
Information Gathering Interview
Highly Structured
Controlled by the Nurse
Elicits specific information
Nurse uses directive questions
Directive Interview
Rapport – building interview
Controlled by the client
Non – Directive Interview
Combination of non – directive and
directive interview
Information Gathering Interview
Used in directive interview
Answerable only by Yes or No
Closed Questions
Used in non – directive interview
Invites client to explore, elaborate, clarify
thoughts or feelings
Open-Ended Questions
