PPT_Chapter02.pptx

Chapter 2 Collecting Subjective Data: The Interview and Health History Interviewing In the preintroductory phase the nurse reviews the medical record which may reveal the client's past health history and reason for seeking health care before meeting with the client to assist with conduc...

Chapter 2 Collecting Subjective Data: The Interview and Health History Interviewing In the preintroductory phase the nurse reviews the medical record which may reveal the client's past health history and reason for seeking health care before meeting with the client to assist with conducting the interview.  Phases of the interview o Introductory o Working o Summary and closing Copyright © 2018 Wolters Kluwer · All Rights Reserved Introductory Phase  Introduction  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 that the client is comfortable and has privacy  Developing trust and rapport using verbal and nonverbal skills Copyright © 2018 Wolters Kluwer · All Rights Reserved Working Phase #2  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 © 2018 Wolters Kluwer · All Rights Reserved Working Phase #3  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 © 2018 Wolters Kluwer · All Rights Reserved 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 Copyright © 2018 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 © 2018 Wolters Kluwer · All Rights Reserved Answer to Question #1 True. A client’s feelings and perceptions may be recorded as subjective data. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nonverbal Communication  Appearance  Demeanor  Facial expression  Attitude  Silence  Listening Copyright © 2018 Wolters Kluwer · All Rights Reserved Nonverbal Communication to Avoid  Excessive or insufficient eye contact  Distraction and distance  Standing Copyright © 2018 Wolters Kluwer · All Rights Reserved Verbal Communication  Open-ended questions  Closed-ended questions  Laundry list  Rephrasing  Well-placed phrases  Inferring  Providing information Copyright © 2018 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 © 2018 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 © 2018 Wolters Kluwer · All Rights Reserved Verbal Communication to Avoid  Biased or leading questions  Rushing through the interview  Reading the questions Copyright © 2018 Wolters Kluwer · All Rights Reserved Special Considerations  Gerontologic variations  Cultural variations  Emotional variations Copyright © 2018 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 © 2018 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 © 2018 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 © 2018 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 © 2018 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 © 2018 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 © 2018 Wolters Kluwer · All Rights Reserved 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 © 2018 Wolters Kluwer · All Rights Reserved Health History—Biographical Data #1  Name  Address  Phone  Gender  Provider of history (patient or other)  Birth date  Place of birth Copyright © 2018 Wolters Kluwer · All Rights Reserved Health History—Biographical Data #2  Race or ethnic background  Primary and secondary languages (spoken and read)  Marital status  Religious or spiritual practices  Educational level  Occupation  Significant others or support persons (availability) Copyright © 2018 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 © 2018 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 © 2018 Wolters Kluwer · All Rights Reserved Review of Body Systems #1  Skin, hair, nails  Head, neck  Eyes  Ears  Mouth, throat, nose, sinuses  Thorax, lungs Copyright © 2018 Wolters Kluwer · All Rights Reserved Review of Body Systems #2  Breasts, regional lymphatics  Heart, neck vessels  Peripheral vascular  Abdomen  Genitalia  Anus, rectum, prostate  Musculoskeletal  Neurologic Copyright © 2018 Wolters Kluwer · All Rights Reserved Lifestyle and Health Practices #1  Description of typical day (AM to PM)  Nutrition and weight management  24-hour dietary intake (foods and fluids)  Who purchases and prepares meals  Activity on a typical day and exercise habits and patterns  Rest and sleep habits and patterns  Medication and substance use  Self-concept and self-care responsibilities Copyright © 2018 Wolters Kluwer · All Rights Reserved Lifestyle and Health Practices #2  Social activities  Relationships  Values and belief system  Past, present and future education and work  Type of work, level of job satisfaction, work stressors  Stress levels and coping strategies  Residency, environment, neighborhood, environmental risks Copyright © 2018 Wolters Kluwer · All Rights Reserved