Subjective and Objective Data in Patient Communication

Subjective vs. Objective Data

• Subjective data encompasses what the patient says, including pain and feelings
• Objective data is what is observed, such as measured metrics and data gathered through the five senses

Communication Techniques

• Communication techniques include gerontologic, cultural, and emotional considerations

Verbal Communication - DOs

• Utilize open-ended questions to encourage detailed responses
• Employ a laundry list approach to cover multiple options efficiently
• Use rephrasing to confirm understanding and show engagement
• Incorporate well-placed phrases to guide the conversation

Verbal Communication - DON'Ts

• Avoid providing false assurance or premature reassurance
• Refrain from giving unwanted advice
• Do not use authority to influence the patient
• Avoidance language and overly professional terminology should not be used
• Steer clear of leading or biased questions
• Do not give inappropriate hope
• Avoid rushing through the interview process
• Reading questions verbatim should be avoided

Nonverbal Communication - DOs

• Pay attention to appearance to convey professionalism and respect
• Maintain a calm and reassuring demeanor
• Use appropriate facial expressions to show empathy
• Display a positive and attentive attitude
• Utilize silence to allow the patient time to reflect
• Practice active listening to fully understand the patients concerns

Nonverbal Communication - DON'Ts

• Avoid excessive or insufficient eye contact
• Minimize distractions and maintain an appropriate distance
• Avoid standing, which can create a power dynamic

Types of Information Collected in an Interview

• Biographical data includes basic patient information
• The reason for seeking care explains the patients motivation for the visit
• The history of present health concern details the current issue
• Past health history covers previous medical conditions and treatments
• Family history includes relevant medical information about the patients family
• Review of Systems (ROS) covers current health problems
• Lifestyle and health practices includes information on diet, exercise, etc
• Developmental level assesses the patients current stage of development

Assessment Types

• Emergency assessments are for sudden onset issues like acute abdominal pain
• Focused assessments are for follow-up care
• Ongoing/Partial assessments are for chronic conditions like lung cancer, focusing on color, temp, and oxygenation
• Initial assessments are complete evaluations that include subjective and objective data and the patients perceived health history

Health History Components

• Health history includes personal history, family history, ROS, and chief complaint
• Personal history includes birth, growth, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents/injuries, pain experiences, and emotional/psych problems
• Family history includes health and causes of death of family members

Review of Systems (ROS)

• ROS includes exterior (skin, hair, nails)
• HEENT (head, eyes, ears, neck, throat, mouth, nose, sinuses)
• Respiratory (lungs, thorax), cardiovascular (heart, neck, vessels, peripheral vascular), abdomen, genitalia/breast/lymph
• Genitourinary (anus, rectum, urinary, prostate), musculoskeletal, and neurologic systems

General Survey Components

• General survey assesses physical and sexual development
• Apparent age vs. reported age
• Skin condition & color
• Dress & hygiene, posture & gait, and level of consciousness
• Behavior, body movements, affect and facial expression, and speech

Vital Signs

• Normal oral temperature is 96.0-99.9 F
• Normal pulse is 60-100 beats/min (0: absent, 1+: weak/diminished, 2+: normal, 3+: bounding)
• Normal blood pressure: 120/80
• Normal respirations: 12-20 breaths/min
• Normal oxygen saturation: 95-100%

PQRST - Pain Assessment

• Provocation: What triggers or alleviates the pain?
• Quality: Describe the pain (sharp, dull, throbbing)?
• Region: Where is the pain located, and does it spread?
• Severity: How intense is the pain on a scale of 0-10?
• Timing: When does the pain occur, and how long does it last?

Types of Pain

• Psychological pain is emotional or mental in origin
• Psychosomatic or psychogenic pain originates from psychological factors but manifests physically
• Nociceptive pain occurs when nerve receptors detect harmful stimuli
• Neuropathic pain results from damage or dysfunction in the nervous system
• Inflammatory pain is due to inflammatory and immune responses
• Somatic pain arises from stimuli in tissues activating nerve receptors
• Visceral pain is caused by stimulation of nerves in internal organs
• Radicular pain is generated by stimuli at the nerve root of spinal nerves
• Phantom pain is felt in a part of the body that has been removed
• Cancer pain can be acute, chronic, nerve, bone, tissue, referred, phantom, or inflammatory
• Referred pain is felt at a location distant from the actual source

Assessment Setting

• Provide a comfortable, warm temperature
• Ensure a private, interruption-free area
• Maintain a quiet environment with adequate lighting

Older Adult Considerations

• Assess mental status and judgement
• Differentiate between dementia (affects cognitive function and functionality) and delirium (affects attention and awareness)

Glasgow Coma Scale (GCS)

• Used to assess the level of consciousness in patients with brain injuries
• Eye Opening Response: Spontaneous (4 points), To verbal command (3 points), To pain (2 points), No opening (1 point)
• Verbal Response: Oriented (5 points), Confused (4 points), Inappropriate (3 points), Incomprehensible (2 points), No response (1 point)
• Motor Response: Obeys commands (6 points), Purposeful movement to pain (5 points), Withdraws from pain (4 points), Abnormal flexion (3 points), Extension (2 points), No response (1 point)
• Minor brain injury: 13-15 points, moderate: 9-12, severe: 3-8 points

Additional Considerations

• Different levels of consciousness include lethargy, obtunded, stupor, and coma
• Mental status examination assesses timing, judgment, concentration, memory, and reasoning
• Nutrition assessments identify risks for obesity and dietary deficits, guides health promotion/disease prevention, gathers insights, and considers cultural beliefs
• BMI indicates underweight (less than 18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-34.9), and extremely obese (35+)

Signs/Symptoms of Malnutrition

• Skin: Dry, flaky skin, poor skin turgor, sores that do not heal
• Hair: Thinning, dry hair
• Nails: Spoon shaped and brittle, cracks at corners of mouth
• Cardiovascular: Edema, tachycardia and hypotension
• Gastrointestinal: Ascites
• Musculoskeletal: Bone wasting and pain
• Neurologic: Altered mental status

Neuro Exam: Cranial Nerves

• I Olfactory: sense of smell
• II Optic: visual acuity
• III Oculomotor: sight
• IV Trochlear: sight
• V Trigeminal: motor (clench teeth), sensory (dull/sharp)
• VI Abducens: sight
• VII Facial: smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, close eyes tightly against resistance
• VIII Acoustic, vestibulocochlear: whisper test
• IX Glossopharyngeal: say "ah"
• X Vagus: ability to swallow
• XI Spinal accessory: shrug shoulders against resistance, sternocleidomastoid
• XII Hypoglossal: move tongue side to side

Other

• The general assessment should be normal/abnormal
• Interview patients for information