lecture 3: information gathering

Question 1

Therapeutic communication (TC)

Answer 1

technique that involves knowledge of verbal and non-verbal communication patterns

Question 2

what is therapeutic interviewing?

Answer 2

1. obtain a health history
2. identify health needs and risk factors
3. determine changes in level of wellness
4. help clients understand their condition

Question 3

effective communication: verbal

Answer 3

active listening: focus on patients and their perspective, search for meanings behind subtleties (trying to be subtle)

Question 4

verbal communication: therapeutic vs. non-therapeutic

Answer 4

therapeutic:
- active listening
- asking relevant questions
- reflection

non-therapeutic:
- false reassurance
- arguing
- interrupting
- unwanted advice

Question 5

effective communication: non-verbal

Answer 5

• personal appearance
• posture
• facial expressions
• eye contact

Question 6

Gathering data: types of data

Answer 6

subjective data: anything said by the patient/family (symptoms)

objective data: observed by the nurse (signs)

ex. nausea (subjective), vomiting (objective/subjective), medications (subjective)

Question 7

gathering data: sources of data

Answer 7

primary source: the patient

secondary source: charts and family members

ex. parent of 6-month old (primary), Wife speaking for husband (secondary)

Question 8

gathering data: reliability of the source

Answer 8

in an instance of a unreliable or inaccurate historian (dementia, under the influence, embarrassed/guilty/scared)

nurse should…
- record person who provides the info
- note any discrepancies (slurred speech, smell of alcohol)
- identify other sources (previous records)

Question 9

types of health histories

Answer 9

comprehensive: long history of patient (check-ups)
focused: based on presenting symptom (twisted ankle)
emergent: emergency history

Question 10

phases of interview process

Answer 10

1. pre-interactive phase - before the client is present
2. beginning phase - sets the tone
3. working phase - open & closed ended questions
4. closing phase - wrap up, next steps

Question 11

Nursing Health history 101

Answer 11

• purpose is to obtain subjective data
• choose questions to ask based on patient’s context/symptoms

ex. patient has abdominal pain, ask about diet, bowel movement