UNIT TWO — NURSING DATA COLLECTION, DOCUMENTATION & ANALYSIS Flashcards
a purposeful, time-limited verbal interaction between the nurse and the patient or his/her significant other.
Nursing Interview
done to collective subjective data about the patient
Nursing Interview
Factors Influencing the Interview
approach, environment, confidentiality, note-taking, time length duration, biases and preconception
gather all appropriate information before approaching the patient
Approach
begin by introducing your name & title.
Approach
INITIALLY, call the patient by his/her formal name & ask
how the patient prefers to be addressed.
Approach
has a direct influence on the amount & quality of information gathered.
environment
ideal setting for interview: private room, less distractions/interruptions, & increase comfort level for the patient
environment
essential in developing trust.
confidentiality
verbal assurance of confidentiality often eases the patient’s concerns.
confidentiality
reasons for sharing confidential information:
✓ patient poses danger to self or others.
✓ Institutional policy (inform the patient prior when the info should be shared).
advisable but may cause patient discomfort.
Note-Taking
explain the necessity of jotting down
pertinent information
Note-Taking
show to patient the form you will be using.
Note-Taking
pay attention to patient & defer recording if
patient discusses sensitive issues.
Note-Taking
pay attention to patient & defer recording if
patient discusses sensitive issues.
Note-Taking
jot down phrases, words, & dates that can
be used.
Note-Taking
interview times should be least disruptive to patient’s daily routine, & try to accommodate patient’s request.
Time, Length, Duration
be sensitive to personal as well as patient contexts in order to treat all patients fairly & respectfully.
Biases & Preconceptions
avoid faulty assumptions by continually validating information & personal impressions (use effective interview techniques).
Biases & Preconceptions
stages of the interview process.
introductory stage, working stage, termination stage
factors affecting communication
active listening, nonverbal cues, distance/proxemics, personal space
primary goal: to decode patient messages in order to understand the situation or problem as the other person sees it.
Active Listening
always pay particular attention &
formulate an appropriate response.
Active Listening
communicating a message without words
Nonverbal Cues
may include: body position, nervous repetitive movements of the hands or legs, rapid blinking, lack of eye contact, yawning, fidgeting, excessive smiling or frowning, repetitive clearing of the throat, etc.
Nonverbal Cues
nthe amount of space a person considers appropriate for interaction is a significant factor in the interview process and is determined in part by cultural influences
Distance/Proxemics (proximity
intimate zone
<18 inches fr. the patient
personal distance
18 inches to 4 feet
social distance
4 to 12 feet
public distance
> 12 feet
the space over which the person claims ownership (e.g. patient’s hospital room & bathroom).
personal space
patient may be protective over this space & consider unauthorized use of it as an invasion of privacy.
personal space
non-therapeutic interview techniques
requesting an explanation, probing, offering false reassurance, giving approval or disapproval, advising, using problematic questioning techniques
encourages patient to provide general rather than
more focused communication.
Using Open-Ended Questions
restrict or regulate patient response to a “yes”, a
“no” or a response less than 3 words.
Using Close-Ended Questions
used to focus the interview, pinpoint specific areas
of concern, & elicit valuable information quickly &
efficiently
Using Close-Ended Questions
can disrupt communication if frequently used.
Using Close-Ended Questions
encourages patient to continue talking.
Facilitating
coupled with nonverbal cues - eye contact, nodding
& leaning slightly forward,
Facilitating
helps structure & pace the interview, convey respect
& acceptance, and prompt additional patient data
Using Silence
on the part of the patient, may convey anxiety,
confusion or embarrassment.
Using Silence
the nurse verbalizes perceptions about the patient’s behavior, then shares them with the patient.
Making Observations
involves repeating or rephrasing the main idea expressed by the patient & lets the patient know that you are paying attention.
Restating
the nurse directs the patient’s own questions, feelings & ideas back to the patient & provides opportunity for the patient to reconsider &/or expand on what was said.
Reflecting
used by the nurse to make clear something the patient says or to pinpoint something in the message when the patient’s words & nonverbal cues do not agree
Clarifying
enables the nurse to link events that perhaps the
patient was not able to piece together.
Interpreting
involves asking the patient to place a symptom, a problem, or an event in its proper sequence.
Sequencing
facilitating the conversation such that occurrence of symptoms/events are pieced together chronologically by patient
Sequencing
helps the patient to deal more effectively with unfamiliar situations by placing the symptoms or problems in the context of something else that is familiar
Encouraging Comparisons
especially useful at the end of the health assessment interview.
summarizing
also provides a means of smoothly transitioning to a new topic or section of the health assessment
Summarizing
allows the nurse to concentrate on or “track” a specific point the patient has made.
focusing
useful to patients w/ heightened anxiety & altered
concentration, or jumping from topic to topic.
focusing
enables the nurse to develop, in more detail, a specific area of content or patient concern.
Exploring
helps the nurse identify patterns or themes in symptom presentation or in the way patients handle problems or health concerns.
Exploring
typically used with psychiatric or confused patients, or to patients who exaggerate or make grandiose statements.
Presenting Reality
done in a non argumentative way, encourages patient to rethink a statement and perhaps modify it.
Presenting Reality
a verbal response that the nurse makes to some perceived discrepancy or incongruency in the patient’s thoughts, feelings, or behaviors
can be used to focus the patient’s attention on some aspect of behavior that, if changed, could lead to more effective functioning.
Confronting
done in a caring, empathetic manner, rather than a critical or accusatory one.
Confronting
providing the patient with needed information, such as explaining the nature and/or the reasons for any necessary tests or procedures
Informing
allows the nurse to help patients become aware of possible choices & then evaluate those choices correctly.
Informing
the nurse & patient work together, rather than the nurse taking control of the interaction.
collaborating
conveys the message that the patient has important knowledge and information to share & encourages active involvement of patient in their own health care, in setting goals, in gathering information, & in problem solving.
collaborating
setting specific limits on inappropriate patient behavior; such situations may include:
a. sexually aggressive pt.
b. hostile pt.
c. talkative pt.
Limit Setting
provide guidance by calmly, clearly, and respectfully telling the patient what behavior is expected.
Limit Setting
imit only the behavior that is problematic or detrimental to the purpose of the interview and avoid making a “big issue” of whatever it is that the patient is doing.
Limit Setting
do not argue or use empty threats or promises, but do offer the patient alternatives.
Limit Setting
allows the nurse to offer appropriate reassurance that the patient’s response may be quite common for the situation and helps decrease patient’s anxiety and fear of being misunderstood.
Normalizing
