Subjective Data Flashcards
3 stages of nursing interview
Introductory Stage, Working Stage, Termination Stage
Non-Verbal Communication
Appearance, Demeanor, Facial Expression, Attitude, Silence, Listening
Verbal Communication
Open-ended questions, Closed-ended questions, Laundry List, Rephrasing, Well placed phrases, Providing Information, Inferring
Communication To Avoid
Excessive or Insufficient Eye Contact, Distraction and Distance, Standing, Biased or Leading Questions, Rushing through the interview, Reading the Questions
Variations of Communication
Gerontologic, Cultural, Emotional
8 Sections of Health History
Biographical Data, Reasons for seeking health care, History of present illness/health concern, Past Health History, Family Health History, ROS (Review of systems), Lifestyle & Health Practices Profile, Developmental level
Role of The Nurse in Introductory Stage
Introduction of the nurse to the client , Explain the reason for taking notes, Ensure that the client is comfortable and has privacy, Develop trust and rapport
Role of the Nurse in Working Stage
Elicit the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, ROS, lifestyle and health practices and developmental level
Listens observes cues and uses critical nursing skills to interpret and validate information received
Role of the Nurse in Termination Stage
Summarizes and validates the information
Identifies and discussed possible plans to resolve the problem of the client
Makes sure to ask if anything else concerns the client and if there are further questions
Appearance
Professional in appearance
Wear comfortable, neat clothes
Wear your name tag
Neat hair and not in extreme style
Fingernails are short and neat
Jewelry minimal
Demeanor
No laughing out loud
Do not yell at your co-worker
Greet the client calmly and focus your full attention on her
Do not be overwhelmingly friendly or touchy
Maintain a professional distance
Facial Expression
Expression should be neutral and friendly
Appear understanding and concern
Attitude
Develop a non judgemental attitude
Do not act superior to the client or appear shocked, disgusted or surprised at what you are told
Do not try preaching to the client or imposing your own sense of ethics or morality
Avoid telling the patient that he or she is foolish or force guilt
Silence
Periods of silence allow the nurse and the client to reflect and organize thoughts
Listening
Most important skill learn and develop
Maintain good eye contact
Smile or display an open appropriate facial expression
Maintain an open arms and hands and lean forward
Avoid preconceived ideas or biases
Avoid crossing your arms, sitting back, tilting your head away from the client, thinking about other things or looking blank and inattentive
Keep an open mind
Use to elicit the client’s feelings and perceptions
Questions begin with HOW and WHAT
Open ended questions
Closed ended questions
Used to obtain facts and to focus on specific information
Questions begin with a WHEN and DID
Used to clarify or obtain more accurate information about issues
Rephrasing
An effective way to communicate during the interview
Helps to clarify information the client has stated
Enables the client reflect on what was said
Well-placed phrases
Properly used phrase will encourage the client to continue
Inferring
Will elicit more data or verify existing data
Be careful not to lead the client to answers that are not true
Assess hearing acuity
Gerontologic
Reluctance to reveal personal information
Cultural
Show respect to the client
Gerontologic
Seek help from experts if there is misunderstanding or difficulty in communicating with the client
Cultural
Variations in willingness to openly express emotional distress or pain
Cultural
Variation in ability to receive information
Cultural
Variation in meaning conveyed by language
Cultural
Variation in use and meaning of non verbal communication: eye contact, gestures
Cultural
Variation in disease/illness perception
Cultural
Variation in past,present and future orientation
Cultural
Variation in the family’s role in the decision making process
Cultural
Assure your elderly client that you are concern
Gerontologic
Speak clearly and use straightforward language during the interview
Gerontologic
Ask questions in simple terms
Gerontologic
Avoid medical jargon and modern slang
Gerontologic
Do not talk down to the client
Gerontologic
Emotions vary for several reasons
Emotional
Include information that identifies the client
Biographical Data
This takes into account several aspects of the health problem: CHARACTER, ONSET, LOCATION, DURATION, SEVERITY,PATTERN, ASSOCIATED FACTORS
History of Present Illness/ Health Concern
Questions related to the client’s past, from the earliest beginnings to the present
Past Health History
This elicit data to the client’s strengths and weaknesses
Past Health History
Discover genetically based problems
Family Health History
Provide client with a choice of words to choose from in describing symptoms
Laundry List
Providing Information
Answer every question well
Explain well to the client what is being observed
Encourage the client to discuss fears or other feelings about having to see a health care provider
Reasons for seeking health care (chief complaints)
Helps the nurse to obtain specific answers and reduces the likelihood of the client’s perceiving or providing an expected answer
Laundry List
This will cause the patient to provide answers that may or may not be true
Biased or leading questions
Take time with the client to show that you are concern about their health and helps them to open up
Rushing through the interview
A____ will help to organize and illustrate the client’s family history
Genogram
The body systems is addressed and the client is asked specific questions to draw out current health problems or problems from recent past that may still affect the client or that are recurring
ROS (REVIEW OF SYSTEMS)
Documents the client’s description of her health status for each body system and note the client’s denial of signs, symptoms, diseases or problems the nurse asked but not experienced by the client
Review of Systems (ROS)
Deals with the client’s human responses that include: nutritional habits, activity & exercise patterns, sleep and rest, self-concept & self- care activities, social community activity, relationship values and beliefs system, education and work, stress level and coping style, environment, developmental level
Lifestyle and Health Practices Profile
Is designed to teach people what types and amount of food to eat to ensure a balanced diet, to promote health and prevent disease
Food pyramid
Assess how active is the patient either at work or at home
Activity & Exercise patterns
Distinguish between activity done at work which is stressful, and exercise which is designed to reduce stress and strengthen the individual
Activity & Exercise Patterns
Explain to the client that regular exercise reduces the risk of heart disease, strengthens heart and lungs, reduces stress and manages weight
Activity & Exercise Patterns
Ask patient on the specific sleep pattern; problem in sleeping, rituals the patient use to promote sleep
Sleep & Rest
Remember that sleep requirements vary depending on age, health and stress levels
Sleep & Rest
Includes assessment of how the client view herself and investigation of all behaviors that a person does to promote her health
Self concept & Self care Activities
Questions on this area helps the nurse to discover what outlets the client has for support and relaxation
Social and Community Activity
Ask client to describe the composition of the family into which they were born and the current and past relationship with these family members
Relationship Values and Beliefs System
This will help to identify areas of stress and satisfaction in the client’s life
EDUCATION AND WORK
Ask what events caused stress and how the patient respond
Stress level and Coping style
To assess health hazards unique to the client’s living situation and lifestyle
ENVIRONMENT
Helps in determining developmental impairments
Developmental level
