4 subjective data

nursing, health, assessment, carmela domocmat, gathering subjective data

1. Collection of subjective data
Maria Carmela L. Domocmat, RN, MSN

2. Subjective data
Sare data that are elicited and verified only by the
client
Sobtained through interviewing
Maria Carmela L. Domocmat, RN, MSN

3. Sconsist of:
• sensations or symptoms (such as pain, hunger)
• preferences
•
feelings (such as happiness or sadness)
•
feelings (such as happiness or sadness)
• beliefs
• perceptions
• values
• desires
• Ideas
• personal information
Maria Carmela L. Domocmat, RN, MSN

4. • Skills needed to obtain data
–Interview and therapies communication skills
–Caring ability and empathy
–
Listening skills
–
Listening skills
Maria Carmela L. Domocmat, RN, MSN

5. –helps provide the following data
• clues to possible physiologic, psychological, and
sociological problems
• reveal a client’s risk for a problem as well as areas of
strengths for the client strengths for the client
Maria Carmela L. Domocmat, RN, MSN

6. Complete Health History
–Biographical data
–Reasons for seeking health care
–History of Present Health concerns
–
Past health history
–
Past health history
–Family health history
–Review of body systems (especially for current
health problems)
–Lifestyle and health practices profile
–Developmental level
Maria Carmela L. Domocmat, RN, MSN

7. NURSING INTERVIEW
Maria Carmela L. Domocmat, RN, MSN

8. Nursing Interview
• a communication process that focuses on:
–establishing rapport and a trusting relationship w ith
the client to elicit accurate and meaningful
information information
–gathering information on the client’s developmenta l,
psychological, sociocultural, and spiritual statuse s to
identify deviations that can be treated with nursin g
and collaborative interventions or strengths that c an
be enhanced with nurse-client collaboration
Maria Carmela L. Domocmat, RN, MSN

9. Phases of the interview
• Phase I: Preinteraction
• Phase II: Introductory Phase
• Phase III: Working phase
•
Phase IV: Summary and Closing Phase
•
Phase IV: Summary and Closing Phase
Maria Carmela L. Domocmat, RN, MSN

10. Preinteraction
uGather data from medical records, other health
personnel
uReview relevant literature
u
Plan the setting and time for the initial interview
u
Plan the setting and time for the initial interview
Maria Carmela L. Domocmat, RN, MSN

11. Introductory Phase
uEstablish a nurse-client relationship/ rapport
uDescribe the purpose of the interview
uAssure the client that the confidential data will
remain confidential remain confidential
uMake sure the client is comfortable (physically
and emotionally) and has privacy
Maria Carmela L. Domocmat, RN, MSN

12. Working phase
uInterview the client about his health history
uNurse and client collaborate to identify the
client’s problems and goals.
u
Use information to plan the physical
u
Use information to plan the physical examination
Maria Carmela L. Domocmat, RN, MSN

13. Summary and Closing Phase
uSummarize information obtained and validates
problems and goals with the client
uIdentify possible plans to resolve the problem
(nursing diagnoses and collaborative problems) with (nursing diagnoses and collaborative problems) with the client.
uAsk if anything else concerns the client and if the re
are any further questions
uDocument health history data
uValidate the data with secondary sources if
necessary
Maria Carmela L. Domocmat, RN, MSN

14. COMMUNICATION DURING
INTERVIEW
Maria Carmela L. Domocmat, RN, MSN

15. Communication during interview
• Nonverbal communication
• Verbal communication
Maria Carmela L. Domocmat, RN, MSN

16. Communication during interview
• Nonverbal communication
–Appearance:
–Demeanor
–
Facial expression
–
Facial expression
–Attitude
–Silence
–Listening
Maria Carmela L. Domocmat, RN, MSN

17. Communication during interview
• Nonverbal communication
–Appearance:
• ensure that your appearance is professional
•
Comfortable, neat clothes
•
Comfortable, neat clothes
• Hair, nail, jewelry
–Demeanor
• Be professional
• Maintain professional distance
Maria Carmela L. Domocmat, RN, MSN

18. Communication during interview
• Nonverbal communication
–Facial expression
• Keep expression neutral and friendly
•
Use right expression at the right time
•
Use right expression at the right time
–Attitude
• Nonjudgmental attitude
• Do not preach to the client or impose your own sense of
ethics
Maria Carmela L. Domocmat, RN, MSN

19. Communication during interview
•Nonverbal communication
–Silence
•Periods of silence allow you and the client to
reflect and organize thoughts, which facilitates reflect and organize thoughts, which facilitates more accurate reporting and data collection
–Listening
• Most important skill to learn
• Maintain good eye contact, smile or display open,
appropriate facial expression, maintain open body
position
Maria Carmela L. Domocmat, RN, MSN

20. Verbal communication
• Open-ended questions
• Closed-ended questions
• Laundry list
•
Rephrasing
•
Rephrasing
• Well-placed phrases
• Inferring
• Providing information
Maria Carmela L. Domocmat, RN, MSN

21. Verbal communication
• Open-ended questions
–“What”
–“How”
• Closed-ended questions
Maria Carmela L. Domocmat, RN, MSN

22. Verbal communication
• Laundry list
–Provide a choice of words to choose from in
describing symptoms, conditions, or feelings
–
“Is the pain severe, dull, sharp, mild, cutting, or
–
“Is the pain severe, dull, sharp, mild, cutting, or piercing?”
–“Does the pain occur once every year, day, month,
or hour?”
Maria Carmela L. Domocmat, RN, MSN

23. • Rephrasing
–Helps clarify information stated
–Enables nurse and the client to reflect on what wa s
said said
–Ex: Mr. G tells you that he has been really tired and
nauseated for two months and that he is really scar ed
because he fears that he has some horrible disease.
–Paraphrase by saying, “You are thinking you have
serious illness?”
Maria Carmela L. Domocmat, RN, MSN

24. • Well-placed phrases
–Ex: “um-hum,” “Yes,” “I agree”
• Inferring
•
Providing information
•
Providing information
Maria Carmela L. Domocmat, RN, MSN

25. Let’s practice
Maria Carmela L. Domocmat, RN, MSN

26. Practice making open-ended questions
L
Restate each question below so it’s an open-ended
question
L
“Are you feeling better?”
L
“Did you like dinner?”
L
“Are you happy here?”
L
“Are you having pain?”
Maria Carmela L. Domocmat, RN, MSN

27. L
“Are you feeling better?”
L
“Did you like dinner?”
L
“Are you happy here?”
L
Tell me how you’re
feeling?
L
How was your dinner?
L
How do you feel about
L
“Are you happy here?”
L
“Are you having pain?”
L
How do you feel about being here?
L
Describe what you’re
feeling
L
Tell me how you’re
feeling.
Maria Carmela L. Domocmat, RN, MSN

28. Practice clarifying ideas by using reflection and
making open-ended questions
L
Reflection -restating what you hear
L
For each statement below, write a reflective
statement ad an open-ended question hat would help
you to clarify what has been said.
“I’ve been sick off and on for a month.”
L
“I’ve been sick off and on for a month.”
L
“Nothing ever goes right for me.”
L
“I seem to have pain in my side that comes and
goes.”
L
“I’ve had this funny feeling for a week.”
Maria Carmela L. Domocmat, RN, MSN

29. s
“I’ve been sick off and on
for a month.”
s
“So, you’ve been sick off
and on for a month.
What do you mean by
sick on and off?
Maria Carmela L. Domocmat, RN, MSN

30. L
“Nothing ever goes right
for me.”
L
“You feel like nothing
ever goes right for you.
What’s been happening
Maria Carmela L. Domocmat, RN, MSN

31. L
“I seem to have pain in
my side that comes and
goes.”
L
“You have a pain on your
side that comes and
goes—can you explain
more?
Maria Carmela L. Domocmat, RN, MSN

32. s
“I’ve had this funny
feeling for a week.”
s
“You’ve had a funny
feeling for a week. What
do you mean by funny?
Maria Carmela L. Domocmat, RN, MSN

33. Test your knowledge of
communication techniques
Maria Carmela L. Domocmat, RN, MSN

34. L
Read each statement below and identify whether it i s
an open-ended statement (O), a closed-ended
statement ©, a leading question (L), an exploratory
statement (E), or a supplementary phrase or
statement intended to help the person continue (S) statement intended to help the person continue (S)
Maria Carmela L. Domocmat, RN, MSN

35. a)
Are you afraid of dying?
b)
Tell me when this first started
c)
I see
d)
You’re not still afraid to feed Hector, are you?
d)
You’re not still afraid to feed Hector, are you?
e)
How do you think you’ll be doing this at home?
f)
Do you have a history of hypertension in your
family?
g)
And..?
h)
You do want your family to visit, don’t you?
Maria Carmela L. Domocmat, RN, MSN

36. i.
How do you feel about being here?
j.
You don’t need more practice, do you?
k.
Explain what you mean by a “long time”
Maria Carmela L. Domocmat, RN, MSN

37. a)
Are you afraid of dying?
b)
Tell me when this first
started
c)
I see
a)
C -closed-ended
statement
b)
E -an exploratory
statement
c)
S
-
a supplementary
d)
You’re not still afraid to
feed Hector, are you?
e)
How do you think you’ll
be doing this at home?
c)
S
-
a supplementary
phrase or statement
intended to help the
person continue
d)
L -leading question
e)
O -an open-ended
statement
Maria Carmela L. Domocmat, RN, MSN

38. f.
Do you have a history of
hypertension in your
family?
g.
And..?
h.
You do want your family to visit, don’t you?
f)
C -a closed-ended
statement
g)
S -a supplementary
phrase or statement
intended to help the
person continue
to visit, don’t you?
i.
How do you feel about
being here?
j.
You don’t need more
practice, do you?
k.
Explain what you mean
by a “long time”
person continue
h)
L -a leading question
i)
O -an open-ended
statement
j)
L -leading question
k)
E -an exploratory
statement
Maria Carmela L. Domocmat, RN, MSN

39. Maria Carmela L. Domocmat, RN, MSN

40. Maria Carmela L. Domocmat, RN, MSN

41. Special considerations
Maria Carmela L. Domocmat, RN, MSN

42. Gerontologic
• Assess hearing acuity
–Hearing loss normally occurs in age
–Undetected hearing loss is often misinterpreted as
mental slowness or confusion
• What to do:
–Speak slowly
–Face the client at all times during the interview
–Position yourself so that you are speaking on the
side of the client that has the ear with better acu ity
–Do no yell at the client
Maria Carmela L. Domocmat, RN, MSN

43. Gerontologic
• Do not talk down to the elderly –being older
physically does not mean the client is slower
mentally
•
Show respect
•
Show respect
• If client is mentally confused or forgetful, it is
important to have SO present to clarify the data
Maria Carmela L. Domocmat, RN, MSN

44. Cultural
• Be aware of the possible variations in
communication styles
• If difficulty in communication –seek help from
“culture broker” or culture expert. “culture broker” or culture expert.
Maria Carmela L. Domocmat, RN, MSN

45. Emotional
• Anxious
• Angry
• Depressed
•
Manipulative
•
Manipulative
• Seductive
• When discussing sensitive issues
Maria Carmela L. Domocmat, RN, MSN

46. COMPLETE HEALTH HISTORY
Maria Carmela L. Domocmat, RN, MSN

47. Health History
• Biographical data
• Reasons for seeking health care
• History of present health concern
•
Past health history
•
Past health history
• Family health history
Maria Carmela L. Domocmat, RN, MSN

48. Health History
• Review of body systems (especially for current
health problems)
• Lifestyle and health practices profile
•
Developmental level
•
Developmental level
Maria Carmela L. Domocmat, RN, MSN

49. Biographical data
• Name
• Age
• Religion •
Occupation
•
Occupation
Maria Carmela L. Domocmat, RN, MSN

50. Reasons for seeking health care
• “What is your major health problem or concerns
at this time?” –chief complaints
• “How do you feel about having to seek health
care?”
-
encourage the client to discuss fears or
care?”
-
encourage the client to discuss fears or
other feelings about having to see a health care
provider.
Maria Carmela L. Domocmat, RN, MSN

51. History of Present Health concerns
• Mnemonic: COLDSPA, PQRST
Maria Carmela L. Domocmat, RN, MSN

52. History of Present Health concerns
•Character: describe the sign or symptom; how
does it feel, look, sound, smell, and so forth?
•Onset: when did it begin?
•
L
ocation: where is it?, does it radiate
•
L
ocation: where is it?, does it radiate
•Duration: how long does it last?
•Severity: how bad is it?
•Pattern: what makes it better? what makes it
worse?
•Associated Factors: what other symptom occur
with it?
Maria Carmela L. Domocmat, RN, MSN

53. COLDSPA
CCCC
haracter
O
nset
L
ocation
COLDSPA
L
ocation
D
uration
S
everity
P
attern
A
ssociated Factors
Maria Carmela L. Domocmat, RN, MSN

54. –
P
–provocative or palliative
–
Q
–quality or quantity
–
R
–region or radiation
–
S
-
severity
–
S
-
severity
–
T
- timing
Maria Carmela L. Domocmat, RN, MSN

55. Past health history
• Birth
• growth & development
• childhood diseases
•
immunizations
• surgeries
• pregnancies
• births
•
previous accidents
•
immunizations
• allergies
• previous health
problems
• hospitalizations
•
previous accidents
• injuries
• pain experiences
• emotional or
psychiatric problems
Maria Carmela L. Domocmat, RN, MSN

56. Family health history
• reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
•
Use genogram
•
Use genogram
Maria Carmela L. Domocmat, RN, MSN

57. Review of body systems
• especially for current health problems
Maria Carmela L. Domocmat, RN, MSN

58. Lifestyle and health practices profile
Include:
• nutritional habits, activity and exercise patterns ,
• sleep and rest patterns,
•
use of medications, & substances
•
use of medications, & substances
Maria Carmela L. Domocmat, RN, MSN

59. Lifestyle and health practices profile
• self-concept & self-care activities
• social and community activities,
• relationships,
•
values and belief system,
•
values and belief system,
• education and work,
Maria Carmela L. Domocmat, RN, MSN

60. Lifestyle and health practices profile
• stress level and coping style, and
• environment.
Maria Carmela L. Domocmat, RN, MSN

61. Social data
• include family relationships, ethnic and
educational background, economic status, home
and neighborhood conditions.
Maria Carmela L. Domocmat, RN, MSN

62. Psychological data
• information about the client’s emotional state.
Maria Carmela L. Domocmat, RN, MSN

63. Pattern of health care
• includes all health care resources: hospitals,
clinics, health centers, family doctors.
Maria Carmela L. Domocmat, RN, MSN

64. Developmental level
Maria Carmela L. Domocmat, RN, MSN