Data Collection & Nursing Interview Techniques PDF

 Process of communication that focuses on: Establishing rapport and trust (elicits accurate and meaningful information/data)  Process of communication that focuses on: Gathering information (to identify deviations that can be treated by independent or collaborative interventi...

 Process of communication that focuses on: Establishing rapport and trust (elicits accurate and meaningful information/data)  Process of communication that focuses on: Gathering information (to identify deviations that can be treated by independent or collaborative interventions) developmental, psychologic, physiologic, sociocultural, and spiritual  Introductory Working Summary and Closure  Introducing self to the client Citing the purpose of the interview Discussion of the types of questions that may be raised  Explaining reason for writing down notes Assurance of confidentiality Ensure privacy  Gathers comments Biographic data Reasons for seeking care Present health concern, etc.  Listens and observes for cues Collaboration of both parties  Summarizes sets of information Identification of possible plans (to resolve the problem and discuss) Clarification is encouraged about the above  Non-verbal Appearance, demeanor, posture, facial expressions, attitude, etc. Verbal Basic necessity to gather information Uses communication strategies  Appearance Present yourself professionally (neat clothes, hair, and name tag with credentials)  Demeanor Upon entering the room, aim for composure Focus is towards the client When uncomfortable, best to maintain professional distance Never be too “touchy” or overwhelmingly friendly  Demeanor NO:laughing loudly yelling with coworker muttering under your breath  Facial Expression Often overlooked aspect of communication Reflects what you are truly thinking Regardless of what you are saying, keep it in check  Attitude Non-judgmental (acceptance regardless of beliefs, ethnicity, lifestyle, and health practices) Means not preaching to client and imposing own ethics and morality → smoking one of the most important non-verbal skills to develop  Silence Allows you and client to reflect and organize thoughts Facilitates more accurate reporting and data collection  Excessive/Insufficient Eye Contact Distraction and Distance Standing  Excessive/Insufficient Eye Contact Avoid extremes in eye contact (in moderation) i.e. EC when client is speaking but look down at your notes from time to time Cultural orientation may also affect clients perception of eye contact with others (nurse)  Distraction and Distance Being preoccupied with something else while asking questions (mentally distant) Gives idea that interview is not important to you  Distraction and Distance Avoid physical distance more than 2-3 feet Rapport and trust are built when client senses your focus and concern entirely on him/her  Study of distance between people in their interactions Four (4) distances: 1.Intimate (0-1.5 feet) 2.Personal (1.5-4 feet) 3.Social (4-12 feet) 4.Public (>12 feet) 1. Intimate zones –This amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety. 2. Personal zone – This distance is comfortable between family and friend who are talking. 3. Social zone – This distance is acceptable for communication in social, work and business settings. 4. Public zone – This is acceptable distance between a speaker and an audience, small groups and other informal functions.  Standing Puts concerned parties at different levels Nurse (higher level) may be perceived as superior Patient care should be a partnership Otherwise → patient may not feel empowered 1.Listening 2.Rephrasing 3.Broad Opening and General Statements 4.Clarification 5.Focusing  Listening Actively and with mindfulness, using all the senses, paying attention to what the client says, does, and feels, as opposed to listening passively with just the ear  Rephrasing Actively listening for the basic message and repeating those thoughts in similar words Patient: “I couldn’t manage to eat any dinner last night – not even dessert.” Nurse: “You had difficulty eating yesterday.” Patient: “Yes, I was very upset when my family left.”  Broad Opening and General Statements Using statements that: Encourage client to verbalize Choose a topic of conversation Facilitate continued verbalization Nurse: “Where would you like to begin?”  Clarification Makes client’s broad overall meaning of message more understandable. Used when paraphrasing is difficult or when communication is garbled Nurse:“I’m not sure I understand that.” “Would you please say that again?”  Focusing Helps client expand on and develop a topic of importance Patient: “My wife says she will look after me, but I don’t think she can, what with the children to take care of, and they’re always after her about something – clothes, homework, what’s for dinner that night.” Nurse: “Sounds like you are worried about how well she can manage.”  Age affects and commonly slows body systems (esp. hearing and visual acuity) Slow physically but not mentally (less medical jargon, talk slower but do not talk down) Has more health concerns than younger patients (they may feel more vulnerable and scared) Not unusual for elderly patients to have health complaints ignored  Willingness to openly express emotional distress or pain Reluctance to reveal personal information Ability to receive information Disease and illness Decision-making process Patient’s Emotional State Proper and Professional Response Anxious Simple and organized information Explain role and purpose Angry Be reassuring, and adopt a calm manner Allow patient to ventilate feelings Avoid arguing Facilitate personal space Depressed Express interest and understanding in a neutral manner Manipulative Structure and set limits Patient with sensitive Be aware of your own thoughts and feelings issues  Serves as groundwork for identifying nursing problems Provides focus for the physical examination Commencement: “..so that I will be able to plan an individualized nursing care with you.”  Biographical Data Chief Complaints Present Health History Past Health History Family History  Psychosocial History Lifestyle and Health Practices Review of Systems  Personal Information Name, address, phone number, sex/gender, informant, birthdate, social security number, medical record number, place of birth, nationality, ethnicity, marital status, educational level, occupation, and other similar data  Question Rationale What is your major health Focus on significant health problem or concerns at this concern time? Answers: “Why are you here?” How do you feel about Encourages discussion of having to seek healthcare? fears and other feelings toward healthcare provider  Considers several aspects of the health problem Detailed description of the concern Symptom Treatments Precipitating factor Expectations (prognosis)  Examples: When did you first notice the pain in your back? How long have you experienced it? Has it become worse, better, or stayed the same since it first occurred?  Factor Specifics Character Feeling, look, sound, and smell Onset When did it begin? Location Where is it? Does it radiate? Duration How long does it last? Severity How bad is it? Grading? Pattern What makes it better or worse? What other symptoms occur with Associated factors sensation? How does it affect you? (pertinent negatives)  Character: The patient describes the pain as a sharp, stabbing sensation  Onset The pain started approximately 12 hours ago while the patient was eating lunch. It began as a mild cramping but quickly intensified.  Location The pain is located in the upper right side of the abdomen, just below the rib cage. It radiates slightly toward the lower back.  Duration The pain has been persistent for the past 12 hours. It has not decreased in intensity and is not relieved by resting or drinking fluids.  Severity The patient rates the pain as 7/10 on the pain scale. It is severe enough to interfere with daily activities and causes some difficulty with breathing when it worsens.  Pattern The pain has remained constant without any significant relief. The patient mentions that it worsens after eating and when moving around, but it does not change with deep breathing.  Associated factors The patient reports feeling nauseous with occasional vomiting, but there is no diarrhea. They have not had any fever but have felt slightly lightheaded.  Related to the client’s past until present condition Elicit data on client strength and weakness Points to trends of unhealthy behavior Information gained assists in identifying risk factors  Birth, growth and development Childhood diseases Immunizations Allergies Previous diseases or hospitalizations  Surgeries Pregnancies Deliveries Accidents Injuries Pain experiences  “Can you tell me how your mother described your birth? Where there any problems? As far as you know, did you progress normally as you grew to adulthood?” “What illnesses or allergies have you had?” “Have you ever been pregnant, and delivered a baby?”  Include as many blood relatives as can be recalled Vertical and horizontal relations Helps identify diseases with a genetic or familial pattern  Genogram → tool used Includes at least three (3) generations Patient is known as the “proband/index patient” Has standard formats Male → Square (left side) Female → Circle (right side) Lines between relatives show relationship  Human responses Nutritional habits Activity and exercise patterns Typical daily pattern/regular exercise plan  Sleep and rest Tell me about your sleeping patterns Do you have trouble falling or staying asleep Use of medications and other substances How much beer, or wine, do you drink on average? Self-concept and self-care activities What do you see as your talents or special abilities?  Social and community activities Relationships who is the most important in your life? Values and belief systems What is the most important to you in life? What gives you hope and strength?  Education and work Educational attainment, work experience Coping style Compensatory behaviors in dealing with stress Stress level Environment  Specific questions draw out current health problems from recent May still affect the client (or may be recurring) Documentation → description of his or her health status for each body system and a notation of client’s comment to the question asked  B Systematic method of evaluating ability to function within the environment Identifies self-care abilities and deficits (in order to match needs with services)  Acquisition of database for use as comparison Identification of individual patient needs and specific self-care deficits Provides foundation to develop individualized plan of care  Provides data for referral to special services (to promote independent health care, day care, or housekeeping service, to promote independent living) Provides means to evaluate treatment and rehabilitation  APGAR Score Ballard Score Denver Developmental Screening Test II (DDST-II) Katz Index of Activities of Daily Living Barthel Index Instrumental Activities of Daily Living  The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed  Six (6) areas of evaluation The more mature the baby is, the higher the score 1.Posture 2.Square Window 3.Arm Recoil 4.Popliteal Angle 5.Scarf Sign 6.Heel to Ear 1. Posture how the baby holds his/her arms and legs 2. Square Window How far the baby’s hands can be flexed toward the wrist 3. Arm Recoil How much baby’s arms “spring back” to flexed position 4. Popliteal Angle How far baby’s knees extend 5. Scarf Sign How far elbows can be moved across the chest 6. Heel to Ear How close the baby’s feet can reach the ears  Used to screen proper development in a child suggests milestones according to the age  Independent → without supervision, direction, or active personal assistance Based on actual status and not ability Patient who can but does not (or refuses) will be considered “not performing” despite being able  Most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living independently. Clinicians typically use the tool to assess function and detect problems in performing activities of daily living and to plan care accordingly.  Six (6) Functions: 1. Bathing (sponge, shower, or tub) 2. Dressing 3. Toileting 4. Transfer 5. Continence 6. Feeding  The Barthel Index (BI) measures the extent to which somebody can function independently and has mobility in their activities of daily living 0-20 =total dependency 21-60=severe dependency 61-90=moderate dependency 91-99=slight dependency  Self-Care Mobility Drinking from a cup Getting in and out of chair Eating Getting on and off toilet Dressing upper body Getting in and out of tub or shower Dressing lower body Walking 50 yards on the level Putting on brace (or artificial limb) Walking up/down one flight of stairs Grooming If not walking: propelling or pushing wheelchair Washing or bathing Controlling urination Controlling bowel movement Action With Help Independent Feeding (if food needs to be cut up → help) 5 10 Moving up from wheelchair to bed and return 5 – 10 15 Handling personal toilet (wash face, comb hair, shave, 0 5 clean teeth) Getting on and off tobilet (handling clothes, wipe, and 5 10 flush) Bathing self 0 5 Walking on level surface (or unable to walk) 0 5 – 15 Ascending and descending stairs 5 10 Dressing (includes tying shoelaces, fastening) 5 10 Controlling bowels 5 10 Controlling bladder 5 10  Evaluates ability to perform more complex personal care activities Addresses activities needed to support independent living (ability to use phone, cook, shop, laundry, manage finances, take medications, and prepare meals)  These skills are considered more complex than the basic activities of daily living as measured by the Katz Index of ADLs  Three-point rating: Independent Needing some help Complete disability