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gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
gathering subjective data
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gathering subjective data

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ways on gathering subjective data or how to interview client.

ways on gathering subjective data or how to interview client.

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  • 1. Collection of subjective data Maria Carmela L. Domocmat, RN, MSN
  • 2. Subjective dataare data that are elicited and verified only by theclientobtained through interviewing Maria Carmela L. Domocmat, RN, MSN
  • 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. • Skills needed to obtain data – Interview and therapies communication skills – Caring ability and empathy – 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 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– 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 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. 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. PreinteractionGather data from medical records, other healthpersonnelReview relevant literaturePlan the setting and time for the initial interview Maria Carmela L. Domocmat, RN, MSN
  • 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. 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. 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. COMMUNICATION DURINGINTERVIEW 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 – 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 • 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 – 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 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• 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 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 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. • Well-placed phrases – Ex: “um-hum,” “Yes,” “I agree”• Inferring• Providing information Maria Carmela L. Domocmat, RN, MSN
  • 25. Let’s practiceMaria Carmela L. Domocmat, RN, MSN
  • 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. “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. 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. “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. “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. “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. “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. Test your knowledge of communication techniquesMaria Carmela L. Domocmat, RN, MSN
  • 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. 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. 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? 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. 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. 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 acuity – Do no yell at the clientDomocmat, RN, MSN Maria Carmela L.
  • 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. 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. Emotional• Anxious• Angry• Depressed• 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• 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 Maria Carmela L. Domocmat, RN, MSN
  • 49. Biographical data• Name• Age• Religion• 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 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?• 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. Character OnsetCOLDSPA Location Duration Severity Pattern Associated FactorsMaria Carmela L. Domocmat, RN, MSN
  • 54. P – provocative or palliativeQ – quality or quantityR – region or radiationS - severityT - timing Maria Carmela L. Domocmat, RN, MSN
  • 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. Family health history• reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).• 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 profileInclude:• nutritional habits, activity and exercise patterns,• sleep and rest patterns,• 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,• 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

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