4 subjective data

2,382
-1

Published on

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

Published in: Health & Medicine, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
2,382
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
19
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

4 subjective data

  1. 1. Collection of subjective data Maria Carmela L. Domocmat, RN, MSN
  2. 2. Subjective dataare data that are elicited and verified only by theclientobtained through interviewing Maria Carmela L. Domocmat, RN, MSN
  3. 3. consist of: • sensations or symptoms (such as pain, hunger) • preferences • feelings (such as happiness or sadness) • beliefs • perceptions • values • desires • Ideas • personal information Maria Carmela L. Domocmat, RN, MSN
  4. 4. • Skills needed to obtain data – Interview and therapies communication skills – Caring ability and empathy – Listening skills Maria Carmela L. Domocmat, RN, MSN
  5. 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 Maria Carmela L. Domocmat, RN, MSN
  6. 6. Complete Health History– Biographical data– Reasons for seeking health care– History of Present Health concerns– 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. 7. NURSING INTERVIEW Maria Carmela L. Domocmat, RN, MSN
  8. 8. Nursing Interview• a communication process that focuses on: – establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information – gathering information on the client’s developmental, psychological, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced with nurse-client collaboration Maria Carmela L. Domocmat, RN, MSN
  9. 9. Phases of the interview• Phase I: Preinteraction• Phase II: Introductory Phase• Phase III: Working phase• Phase IV: Summary and Closing Phase Maria Carmela L. Domocmat, RN, MSN
  10. 10. PreinteractionGather data from medical records, other healthpersonnelReview relevant literaturePlan the setting and time for the initial interview Maria Carmela L. Domocmat, RN, MSN
  11. 11. Introductory PhaseEstablish a nurse-client relationship/ rapportDescribe the purpose of the interviewAssure the client that the confidential data willremain confidentialMake sure the client is comfortable (physicallyand emotionally) and has privacy Maria Carmela L. Domocmat, RN, MSN
  12. 12. Working phaseInterview the client about his health historyNurse and client collaborate to identify theclient’s problems and goals.Use information to plan the physicalexamination Maria Carmela L. Domocmat, RN, MSN
  13. 13. Summary and Closing PhaseSummarize information obtained and validatesproblems and goals with the clientIdentify possible plans to resolve the problem(nursing diagnoses and collaborative problems) withthe client.Ask if anything else concerns the client and if thereare any further questionsDocument health history dataValidate the data with secondary sources ifnecessary Maria Carmela L. Domocmat, RN, MSN
  14. 14. COMMUNICATION DURINGINTERVIEW Maria Carmela L. Domocmat, RN, MSN
  15. 15. Communication during interview• Nonverbal communication• Verbal communication Maria Carmela L. Domocmat, RN, MSN
  16. 16. Communication during interview• Nonverbal communication – Appearance: – Demeanor – Facial expression – Attitude – Silence – Listening Maria Carmela L. Domocmat, RN, MSN
  17. 17. Communication during interview• Nonverbal communication – Appearance: • ensure that your appearance is professional • Comfortable, neat clothes • Hair, nail, jewelry – Demeanor • Be professional • Maintain professional distance Maria Carmela L. Domocmat, RN, MSN
  18. 18. Communication during interview• Nonverbal communication – Facial expression • Keep expression neutral and friendly • 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. 19. Communication during interview• Nonverbal communication – Silence • Periods of silence allow you and the client to 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. 20. Verbal communication• Open-ended questions• Closed-ended questions• Laundry list• Rephrasing• Well-placed phrases• Inferring• Providing information Maria Carmela L. Domocmat, RN, MSN
  21. 21. Verbal communication• Open-ended questions – “What” – “How”• Closed-ended questions Maria Carmela L. Domocmat, RN, MSN
  22. 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 piercing?” – “Does the pain occur once every year, day, month, or hour?” Maria Carmela L. Domocmat, RN, MSN
  23. 23. • Rephrasing – Helps clarify information stated – Enables nurse and the client to reflect on what was said – Ex: Mr. G tells you that he has been really tired and nauseated for two months and that he is really scared 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. 24. • Well-placed phrases – Ex: “um-hum,” “Yes,” “I agree”• Inferring• Providing information Maria Carmela L. Domocmat, RN, MSN
  25. 25. Let’s practiceMaria Carmela L. Domocmat, RN, MSN
  26. 26. Practice making open-ended questions Restate each question below so it’s an open-ended question “Are you feeling better?” “Did you like dinner?” “Are you happy here?” “Are you having pain?”Maria Carmela L. Domocmat, RN, MSN
  27. 27. “Are you feeling better?” Tell me how you’re feeling? “Did you like dinner?” How was your dinner? “Are you happy here?” How do you feel about being here? “Are you having pain?” Describe what you’re feeling Tell me how you’re feeling.Maria Carmela L. Domocmat, RN, MSN
  28. 28. Practice clarifying ideas by using reflection and making open-ended questions Reflection - restating what you hear 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.” “Nothing ever goes right for me.” “I seem to have pain in my side that comes and goes.” “I’ve had this funny feeling for a week.”Maria Carmela L. Domocmat, RN, MSN
  29. 29. “I’ve been sick off and on “So, you’ve been sick off for a month.” and on for a month. What do you mean by sick on and off?Maria Carmela L. Domocmat, RN, MSN
  30. 30. “Nothing ever goes right “You feel like nothing for me.” ever goes right for you. What’s been happeningMaria Carmela L. Domocmat, RN, MSN
  31. 31. “I seem to have pain in “You have a pain on your my side that comes and side that comes and goes.” goes—can you explain more?Maria Carmela L. Domocmat, RN, MSN
  32. 32. “I’ve had this funny “You’ve had a funny feeling for a week.” feeling for a week. What do you mean by funny?Maria Carmela L. Domocmat, RN, MSN
  33. 33. Test your knowledge of communication techniquesMaria Carmela L. Domocmat, RN, MSN
  34. 34. Read each statement below and identify whether it is 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)Maria Carmela L. Domocmat, RN, MSN
  35. 35. a) Are you afraid of dying?b) Tell me when this first startedc) I seed) 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. 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. 37. a) Are you afraid of dying? a) C - closed-endedb) Tell me when this first statement started b) E - an exploratoryc) I see statement c) S - a supplementary phrase or statement intended to help thed) You’re not still afraid to person continue feed Hector, are you? d) L - leading questione) How do you think you’ll be doing this at home? e) O - an open-ended statementMaria Carmela L. Domocmat, RN, MSN
  38. 38. f. Do you have a history of f) C - a closed-ended hypertension in your statement family? g) S - a supplementaryg. And..? phrase or statementh. You do want your family intended to help the to visit, don’t you? person continuei. How do you feel about h) L - a leading question being here? i) O - an open-endedj. You don’t need more statement practice, do you? j) L - leading questionk. Explain what you mean k) E - an exploratory by a “long time” statementMaria Carmela L. Domocmat, RN, MSN
  39. 39. Maria Carmela L. Domocmat, RN, MSN
  40. 40. Maria Carmela L. Domocmat, RN, MSN
  41. 41. Special considerations Maria Carmela L. Domocmat, RN, MSN
  42. 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 acuity – Do no yell at the clientDomocmat, RN, MSN Maria Carmela L.
  43. 43. Gerontologic• Do not talk down to the elderly – being older physically does not mean the client is slower mentally• 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. 44. Cultural• Be aware of the possible variations in communication styles• If difficulty in communication – seek help from “culture broker” or culture expert. Maria Carmela L. Domocmat, RN, MSN
  45. 45. Emotional• Anxious• Angry• Depressed• Manipulative• Seductive• When discussing sensitive issues Maria Carmela L. Domocmat, RN, MSN
  46. 46. COMPLETE HEALTH HISTORY Maria Carmela L. Domocmat, RN, MSN
  47. 47. Health History• Biographical data• Reasons for seeking health care• History of present health concern• Past health history• Family health history Maria Carmela L. Domocmat, RN, MSN
  48. 48. Health History• Review of body systems (especially for current health problems)• Lifestyle and health practices profile• Developmental level Maria Carmela L. Domocmat, RN, MSN
  49. 49. Biographical data• Name• Age• Religion• Occupation Maria Carmela L. Domocmat, RN, MSN
  50. 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 other feelings about having to see a health care provider. Maria Carmela L. Domocmat, RN, MSN
  51. 51. History of Present Health concerns• Mnemonic: COLDSPA, PQRST Maria Carmela L. Domocmat, RN, MSN
  52. 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?• Location: 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 otherMSN Maria Carmela L. Domocmat, RN, symptom occur with it?
  53. 53. Character OnsetCOLDSPA Location Duration Severity Pattern Associated FactorsMaria Carmela L. Domocmat, RN, MSN
  54. 54. P – provocative or palliativeQ – quality or quantityR – region or radiationS - severityT - timing Maria Carmela L. Domocmat, RN, MSN
  55. 55. Past health history• Birth • surgeries• growth & development• pregnancies• childhood diseases • births• immunizations • previous accidents• allergies • injuries• previous health • pain experiences problems • emotional or• hospitalizations psychiatric problems Maria Carmela L. Domocmat, RN, MSN
  56. 56. Family health history• reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).• Use genogram Maria Carmela L. Domocmat, RN, MSN
  57. 57. Review of body systems• especially for current health problems Maria Carmela L. Domocmat, RN, MSN
  58. 58. Lifestyle and health practices profileInclude:• nutritional habits, activity and exercise patterns,• sleep and rest patterns,• use of medications, & substances Maria Carmela L. Domocmat, RN, MSN
  59. 59. Lifestyle and health practices profile• self-concept & self-care activities• social and community activities,• relationships,• values and belief system,• education and work, Maria Carmela L. Domocmat, RN, MSN
  60. 60. Lifestyle and health practices profile• stress level and coping style, and• environment. Maria Carmela L. Domocmat, RN, MSN
  61. 61. Social data• include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. Maria Carmela L. Domocmat, RN, MSN
  62. 62. Psychological data• information about the client’s emotional state. Maria Carmela L. Domocmat, RN, MSN
  63. 63. Pattern of health care• includes all health care resources: hospitals, clinics, health centers, family doctors. Maria Carmela L. Domocmat, RN, MSN
  64. 64. Developmental level Maria Carmela L. Domocmat, RN, MSN

×