Chapter 2: Collecting Subjective Data - Wolters Kluwer

Chapter 2 Collecting Subjective Data: The Interview and Health History Collecting Subjective Data  Sensations or symptoms  Feelings  Perceptions  Desires  Preferences  Beliefs  Ideas  Values  Personal information Copyright © 2022 Wolters Kluwer · All Rights Reserved In...

Chapter 2 Collecting Subjective Data: The Interview and Health History Collecting Subjective Data  Sensations or symptoms  Feelings  Perceptions  Desires  Preferences  Beliefs  Ideas  Values  Personal information Copyright © 2022 Wolters Kluwer · All Rights Reserved Interviewing #1  Requires professional, interpersonal, interviewing skills  Two focuses: o Establishing rapport and trusting relationship with client o Gathering information on developmental, psychological, physiologic, sociocultural, and spiritual status to identify deviations and collaborative interventions or strengths that can be enhanced Copyright © 2022 Wolters Kluwer · All Rights Reserved Interviewing #2  Phases of the interview: o Preintroductory o Introductory o Working o Summary and closing Copyright © 2022 Wolters Kluwer · All Rights Reserved Preintroductory Phase  Nurse reviews medical record before meeting client.  Can reveal information that will help assess current needs  May reveal special considerations for interviewing client  Will guide nurse in obtaining necessary information  If no medical record in system, nurse will need to depend on interviewing skills to elicit all necessary information. Copyright © 2022 Wolters Kluwer · All Rights Reserved Introductory Phase  Introduction  Explain the purpose of the interview  Discuss the types of questions that will be asked  Explain the reason for taking notes  Assure the client that confidential information will remain confidential  Make sure that the client is comfortable and has privacy  Develop trust and rapport using verbal and nonverbal skills Copyright © 2022 Wolters Kluwer · All Rights Reserved Working Phase #1  Biographical data  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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Working Phase #2  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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Summary and Closing Phase  Summarize information obtained during the working phase  Validate problems and goals with the client  Identify and discuss possible plans to resolve the problem with the client  Make sure to ask if anything else concerns the client and if there are any further questions Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? A client’s feelings and perceptions may be recorded as subjective data. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 True A client’s feelings and perceptions may be recorded as subjective data. Copyright © 2022 Wolters Kluwer · All Rights Reserved Nonverbal Communication  Appearance  Demeanor  Facial expression  Attitude  Silence  Listening Copyright © 2022 Wolters Kluwer · All Rights Reserved Nonverbal Communication to Avoid  Excessive or insufficient eye contact  Distraction and distance  Standing Copyright © 2022 Wolters Kluwer · All Rights Reserved Verbal Communication  Open-ended questions  Closed-ended questions  Laundry list  Rephrasing  Well-placed phrases  Inferring  Providing information Copyright © 2022 Wolters Kluwer · All Rights Reserved Verbal Communication to Avoid  Biased or leading questions  Rushing through the interview  Reading the questions Copyright © 2022 Wolters Kluwer · All Rights Reserved Special Considerations During the Interview  Gerontologic variations  Cultural variations  Emotional variations Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? The nurse should use closed-ended questions to elicit the client’s feelings and perceptions. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 False The nurse should use open-ended questions to elicit the client’s feelings and perceptions. Closed-ended questions should be used to obtain facts and to focus on specific information. Copyright © 2022 Wolters Kluwer · All Rights Reserved Interacting With an Anxious Client  Provide the client with simple, organized information in a structured format  Explain who you are and your role and purpose  Ask simple, concise questions  Avoid becoming anxious like the client  Do not hurry  Decrease any external stimuli Copyright © 2022 Wolters Kluwer · All Rights Reserved Interacting With an Angry Client  Approach the client in a calm, reassuring, in-control manner  Allow the client to vent feelings  Avoid any arguments with or touching the client  Obtain help from other health care professionals as needed  Facilitate personal space so that the client does not feel threatened or cornered  Never allow the client to position him or herself between you and the door Copyright © 2022 Wolters Kluwer · All Rights Reserved Interacting With a Depressed Client  Express interest in and understanding of the client and respond in a neutral manner  Take care not to communicate in an upbeat, encouraging manner Copyright © 2022 Wolters Kluwer · All Rights Reserved Interacting With a Manipulative Client  Provide structure and set limits  Differentiate between manipulation and a reasonable request  Obtain an objective opinion from other nursing colleagues Copyright © 2022 Wolters Kluwer · All Rights Reserved Interacting With a Seductive Client  Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors  Encourage client to use more appropriate methods of coping in relating to others  If the overt sexuality continues, do not interact without a witness  Report inappropriate behavior to a supervisor Copyright © 2022 Wolters Kluwer · All Rights Reserved 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 as needed  If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate Copyright © 2022 Wolters Kluwer · All Rights Reserved Working With Interpreters #1  Help interpreter adapt language to client’s level of speech and comprehension  Help interpreter adapt communication for clients who cannot communicate clearly  Help interpreter be aware of cultural language differences  Help interpreter be aware of other potential areas of cultural variation  Help interpreter recognize memory problems and physical distractions may elicit incorrect or insufficient information Copyright © 2022 Wolters Kluwer · All Rights Reserved Working With Interpreters #2  Help interpreter recognize other potential barriers to communication  Prior to interview o Allow extra time for interpreting; determine if simultaneous or consecutive mode of interpretation is to be used; encourage interpreter to let you know of any communication problems  During interview o Introduce self and interpreter; sit looking directly at client; watch client throughout interview; avoid technical jargon; question client at end for any clarification, decisions, or recommendations Copyright © 2022 Wolters Kluwer · All Rights Reserved Complete 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Biographical Data #1  Name  Address  Phone number  Gender  Provider of history (client or other)  Birth date  Social Security number, medical record number, health insurance information, or similar identifying data Copyright © 2022 Wolters Kluwer · All Rights Reserved Biographical Data #2  Culture, ethnicity, subculture o Date and place of birth o Nationality or ethnicity o Marital status o Religious or spiritual practices o Primary and secondary languages (spoken, written, and read)  Educational level  Occupation; Working status  Significant others or support persons (availability) Copyright © 2022 Wolters Kluwer · All Rights Reserved Reason(s) for Seeking Health Care  “What is your major health problem or concern at this time?” o Chief complaint o Client focuses on most significant health concern.  “How do you feel about having to seek health care?” o Encourages client to discuss fears or other feelings about having to see health care provider Copyright © 2022 Wolters Kluwer · All Rights Reserved History of Present Health Concern  Answers to questions provide detailed description of concern  Encourage detailed answers to questions  Use of various assessment tools assist in collecting necessary data  Evaluate client’s insight into problem and plans for managing it  Each identified symptom must be described for clear understanding of probable cause and significance Copyright © 2022 Wolters Kluwer · All Rights Reserved COLDSPA  C: Character  O: Onset  L: Location  D: Duration  S: Severity  P: Pattern  A: Associated factors/how it affects the client Copyright © 2022 Wolters Kluwer · All Rights Reserved PQRST Pain Analysis Mnemonic  P: Provocative/palliative  Q: Quality  R: Radiates  S: Severity  T: Timing Copyright © 2022 Wolters Kluwer · All Rights Reserved Personal Health History  Birth, growth, development  Childhood diseases  Immunizations  Allergies  Medication use: prescription, over the counter  Previous health problems  Hospitalizations, surgeries, pregnancies, births  Previous accidents, injuries  Pain experiences  Emotional or psychiatric problems Copyright © 2022 Wolters Kluwer · All Rights Reserved Family Health History Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Which sign in a genogram indicates adoption? a. A horizontal dotted line b. A vertical dotted line c. An X in a circle d. An X in a square Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 b. A vertical dotted line Rationale: In a genogram, a vertical dotted line may be used to indicate adoption. A horizontal dotted line is used to indicate the client’s spouse. An X in a circle indicates a deceased female client. An X in a square indicates a deceased male client. Copyright © 2022 Wolters Kluwer · All Rights Reserved Review of Systems for Current Health Problems #1  Skin, hair, nails  Head, neck  Eyes  Ears  Mouth, throat, nose, sinuses  Thorax, lungs  Breasts, regional lymphatics Copyright © 2022 Wolters Kluwer · All Rights Reserved Review of Systems for Current Health Problems #2  Heart, neck vessels  Peripheral vascular  Abdomen  Genitalia  Anus, rectum, prostate  Musculoskeletal  Neurologic Copyright © 2022 Wolters Kluwer · All Rights Reserved Lifestyle and Health Practices #1  Description of typical day  Nutrition and weight management o 24-hour dietary intake (foods and fluids) o Who purchases and prepares meals  Activity on a typical day and exercise habits and patterns  Sleep and rest  Substance use  Self-concept and self-care responsibilities Copyright © 2022 Wolters Kluwer · All Rights Reserved Lifestyle and Health Practices #2  Social activities  Relationships  Values and belief system  Education and work o Type of work, level of job satisfaction, work stressors  Stress levels and coping strategies  Environment o Residency, neighborhood, environmental risks Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #4 Is the following statement true or false? When collecting data about the client’s typical day, inquiring about dietary habits is not necessary. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #4 False It is very important to include questions concerning a client’s dietary habits when evaluating the client’s concerns. Many chronic conditions are related to eating and drinking habits and can reveal areas that will need to be addressed when planning the nursing care plan. Copyright © 2022 Wolters Kluwer · All Rights Reserved