Nursing Chapter 2: Collecting Subjective Data

Interviewing

• The nurse reviews the medical record before meeting the client to assist with conducting the interview.
• Phases of the interview:
  • Introductory phase
  • Working phase
  • Summary and closing phase

Introductory Phase

• Introduction to the client
• Explaining the purpose of the interview
• Discussing the types of questions that will be asked
• Explaining the reason for taking notes
• Assuring the client that confidential information will remain confidential
• Making sure the client is comfortable and has privacy
• Developing trust and rapport using verbal and nonverbal skills

Working Phase

• Biographical data collection
• 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
• Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client
• Collaborating with the client to identify the client's problems and goals

Summary and Closing Phase

• Summarizing information obtained during the working phase
• Validating problems and goals with the client
• Identifying and discussing possible plans to resolve the problem with the client
• Making sure to ask if anything else concerns the client and if there are any further questions

Nonverbal Communication

• Importance of appearance, demeanor, facial expression, attitude, silence, and listening
• Nonverbal communication to avoid: excessive or insufficient eye contact, distraction and distance, standing

Verbal Communication

• Open-ended questions
• Closed-ended questions
• Laundry list
• Rephrasing
• Well-placed phrases
• Inferring
• Providing information
• Avoid using biased or leading questions, rushing through the interview, and reading the questions

Special Considerations

• Gerontologic variations
• Cultural variations
• Emotional variations

Interacting with Different Client Types

• Anxious client: provide simple, organized information, explain who you are and your role, ask simple questions, avoid becoming anxious, do not hurry, decrease external stimuli
• Angry client: approach calmly, allow venting, avoid arguments, obtain help from other health care professionals, facilitate personal space
• Depressed client: express interest, respond neutrally, avoid upbeat communication
• Manipulative client: provide structure, set limits, differentiate between manipulation and reasonable requests, obtain objective opinion
• Seductive client: set firm limits, encourage coping, avoid responding to subtle behaviors, report inappropriate behavior

Discussing Sensitive Issues

• Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality
• Ask simple questions in a nonjudgmental manner
• Allow time for ventilation of client's feelings
• If uncomfortable, make referrals to appropriate professionals

Health History

• Biographical data
• Reasons for seeking health care
• History of present health concern
• Past health history
• Family health history
• Review of systems for current health problems
• Lifestyle and health practices
• Developmental level

Review of Body Systems

• Skin, hair, nails
• Head, neck
• Eyes
• Ears
• Mouth, throat, nose, sinuses
• Thorax, lungs
• Breasts, regional lymphatics
• Heart, neck vessels
• Peripheral vascular
• Abdomen
• Genitalia
• Anus, rectum, prostate
• Musculoskeletal
• Neurologic

Lifestyle and Health Practices

• Description of typical day
• Nutrition and weight management
• 24-hour dietary intake
• Who purchases and prepares meals
• Activity on a typical day and exercise habits
• Rest and sleep habits
• Medication and substance use
• Self-concept and self-care responsibilities
• Social activities
• Relationships
• Values and belief system
• Past, present, and future education and work
• Type of work, job satisfaction, work stressors
• Stress levels and coping strategies
• Residency, environment, neighborhood, environmental risks