INTERVIEW Flashcards
Is an integral part of interviewing the client to obtain a nursing health history
Collecting subjective data
What are the 9 ways in collecting subjective data:
•Sensations or symptoms
•Feelings
•Perceptions
•Desires
•Preferences
•Beliefs
•Ideas
•Values
•Personal information
Provide clues to possible physiological, psychological, and sociologic problems
Subjective data
They also provide the nurse with information that may reveal a client’s risk for a problem as well as areas of strengths for the client
Subjective data
Subjective data is obtained through?
Interviewing
Vital for accurate and thorough collection of subjective data
Effective interviewing skills
Obtaining a valid nursing health history requires professional, interpersonal, and _______ skills.
Interviewing
The nursing interview is a communication process that has two focuses:
- Establishing rapport and trusting relationship with a client to elicit accurate meaningful information
- Gathering information on the client’s developmental, psychological, physiological, socio-cultural, and spiritual status to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration
The nurse review the medical record before meeting with the client
Preintroductory 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
Introductory Phase
Conducting the interview at eye level with a client demonstrates respect and places the nurse and the client at equal levels
Introductory phase
At this point in the interview, it is also essential for nurses to develop trust and rapport, which are essential to promote full disclosure of information
Introductory phase
The nurse can began this process by conveying a sense of priority and interest in the client
Introductory phase
Developing rapport depends heavily on verbal and nonverbal communication on the part of the nurse
Introductory phase
During the phase, the nurse ellicits the client’s comments about major biographical data, reason 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 then listens, observes cues, and use critical thinking skills to interpret and validate information received from the client
WORKING PHASE
The nurse and client collaborate to identify the client’s problem and goals
WORKING PHASE
The facilitating approach may be free-flowing or more structured with specific questions, depending on the time available in the type of data needed
WORKING PHASE
The nurse summarizes information obtained during the working phase and validates problems and goals with the client
SUMMARY AND CLOSING PHASE
She also identifies and discusses possible plans to resolve the problem (client concerns and collaborative problems) with the client
SUMMARY AND CLOSING PHASE
The nurse makes sure to ask if anything else concerns the client and if there are any further questions
SUMMARY AND CLOSING PHASE
Your appearance, demeanor, posture, facial expressions, and attitude strongly influence how the client perceives the questions you ask
NON-VERBAL COMMUNICATION
Facilitate eye level contact
NON-VERBAL COMMUNICATION
Effective ________ is essential to a client interview
VERBAL COMMUNICATION
The goal of the interview process is to elicit as much data about the client’s health status as possible
VERBAL COMMUNICATION
7 SEVERAL TYPES OF QUESTIONS AND TECHNIQUES TO USE DURING INTERVIEW:
- Open-Ended questions
- Closed-Ended questions
- Laundry List
- Rephrasing
- Well-Placed Phrases
- Inferring
- Providing Information
3 Special considerations during the interview:
- Gerontologic Variations in Communication
- Cultural Variations in Communication
- Emotional Variations in Communication
The health history 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.
COMPLETE HEALTH HISTORY
Used to identify client’s strengths and limitations in lifestyle and health status
HEALTH HISTORY DATA
8 SECTIONS OF HEALTH HISTORY:
- Biographical data
- Reasons for seeking healthcare
- History of present health concern
- Personal health history
- Family health history
- ROS for current health problems
- Lifestyle and health practices profile
- Developmental level
Used for gathering History of Present Health Concern
COLDSPA
How does it feel, look, smell, and sound
Character
When did it begin? Is it better, worse, or the same since it began?
Onset
Where is it? Does it radiate?
Location
How long does it last? Does it recur?
Duration
How bad is it on a scale of 1 to 10?
Severity
What makes it better? What makes it worse?
Pattern
What other symptoms do you have with it? Will you able to continue doing your work or other activities (leisure or exercise?)
Associated factors
Meaning of COLDSPA mnemonics:
•Character
•Onset
•Location
•Duration
•Severity
•Pattern
•Associated factors
Used for Pain Analysis
PQRST mnemonic
What provokes or relieves the pain?
Provocative/palliative
Describe the character of pain (sharp, stabbing, aching)
Quality
Is the pain localized or does it spread to other areas?
Radiates
How bad is the pain? Does it interfere with your ADLs or sleep?
Severity
When does the pain occur, and how long does it last? How long before it recurs?
Timing
Meaning of mnemonic PQRST
•Provocative/palliative
•Quality
•Radiates
•Severity
•Timing
A complete nursing assessment includes both collection of subjective data and the collection of objective data.
COLLECTING OBJECTIVE DATA:
PHYSICAL EXAM TECHNIQUE
Include information about the client that the nurse directly observes during interaction with a client and information elicited through physical examination techniques
Objective data
TO BECOME PROFICIENT WITH PHYSICAL EXAMINATION SKILLS, THE NURSE MUST HAVE BASIC KNOWLEDGE IN THREE AREAS:
•Types and operation of equipment needed for particular examination (e.g., pen light, sphygmomanometer, otoscope, tuning fork, stethoscope)
•Preparation of the setting, oneself, and the client for physical assessment
•Performance of the four examination techniques:
Inspection
Palpation
Percussion
Auscultation
May take place in a variety of settings such as a hospital room, outpatient clinic, physician’s office, or a client’s home.
Physical examination
The physical examination may take place in a variety of settings such as a hospital room outpatient clinic physicians office school office employee health office or a client’s home
PREPARING THE PHYSICAL SETTINGS
Careful preparation of yourself as an examiner is essential to be able to gather objective data to elicit sound clinical judgment. as a beginner examiner it is helpful to assess your own feelings and anxieties before examining the client
Preparing oneself
