Collection of subjective data Maria Carmela L. Domocmat, RN, MSN
Dec 05, 2014
Collection of subjective data
Maria Carmela L. Domocmat, RN, MSN
Subjective data
� are data that are elicited and verified only by the client
� obtained through interviewing
Maria Carmela L. Domocmat, RN, MSN
� consist 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
• Skills needed to obtain data
– Interview and therapies communication skills
– Caring ability and empathy
– Listening skills – Listening skills
Maria Carmela L. Domocmat, RN, MSN
– 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 clientstrengths for the client
Maria Carmela L. Domocmat, RN, MSN
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
NURSING INTERVIEW
Maria Carmela L. Domocmat, RN, MSN
Nursing Interview
• a communication process that focuses on:
– establishing rapport and a trusting relationship with
the client to elicit accurate and meaningful
informationinformation
– 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
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
Preinteraction
�Gather data from medical records, other health
personnel
�Review relevant literature
�Plan the setting and time for the initial interview�Plan the setting and time for the initial interview
Maria Carmela L. Domocmat, RN, MSN
Introductory Phase
�Establish a nurse-client relationship/ rapport
�Describe the purpose of the interview
�Assure the client that the confidential data will remain confidentialremain confidential
�Make sure the client is comfortable (physically and emotionally) and has privacy
Maria Carmela L. Domocmat, RN, MSN
Working phase
�Interview the client about his health history
�Nurse and client collaborate to identify the client’s problems and goals.
�Use information to plan the physical �Use information to plan the physical examination
Maria Carmela L. Domocmat, RN, MSN
Summary and Closing Phase
�Summarize information obtained and validates
problems and goals with the client
�Identify possible plans to resolve the problem
(nursing diagnoses and collaborative problems) with (nursing diagnoses and collaborative problems) with
the client.
�Ask if anything else concerns the client and if there
are any further questions
�Document health history data
�Validate the data with secondary sources if
necessaryMaria Carmela L. Domocmat, RN, MSN
COMMUNICATION DURING INTERVIEW
Maria Carmela L. Domocmat, RN, MSN
Communication during interview
• Nonverbal communication
• Verbal communication
Maria Carmela L. Domocmat, RN, MSN
Communication during interview
• Nonverbal communication
– Appearance:
– Demeanor
– Facial expression– Facial expression
– Attitude
– Silence
– Listening
Maria Carmela L. Domocmat, RN, MSN
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
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
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
Verbal communication
• Open-ended questions
• Closed-ended questions
• Laundry list
• Rephrasing• Rephrasing
• Well-placed phrases
• Inferring
• Providing information
Maria Carmela L. Domocmat, RN, MSN
Verbal communication
• Open-ended questions
– “What”
– “How”
• Closed-ended questions
Maria Carmela L. Domocmat, RN, MSN
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
• Rephrasing
– Helps clarify information stated
– Enables nurse and the client to reflect on what was
saidsaid
– 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
• Well-placed phrases
– Ex: “um-hum,” “Yes,” “I agree”
• Inferring
• Providing information• Providing information
Maria Carmela L. Domocmat, RN, MSN
Let’s practice
Maria Carmela L. Domocmat, RN, MSN
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
� “Are you feeling better?”
� “Did you like dinner?”
� “Are you happy here?”
� Tell me how you’re feeling?
� How was your dinner?
� How do you feel about � “Are you happy here?”
� “Are you having pain?”
� How do you feel about being here?
� Describe what you’re feeling
� Tell me how you’re feeling.
Maria Carmela L. Domocmat, RN, MSN
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.”� “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
� “I’ve been sick off and on for a month.”
� “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
� “Nothing ever goes right for me.”
� “You feel like nothing ever goes right for you. What’s been happening
Maria Carmela L. Domocmat, RN, MSN
� “I seem to have pain in my side that comes and goes.”
� “You have a pain on your side that comes and goes—can you explain more?
Maria Carmela L. Domocmat, RN, MSN
� “I’ve had this funny feeling for a week.”
� “You’ve had a funny feeling for a week. What do you mean by funny?
Maria Carmela L. Domocmat, RN, MSN
Test your knowledge of communication techniques
Maria Carmela L. Domocmat, RN, MSN
� 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)statement intended to help the person continue (S)
Maria Carmela L. Domocmat, RN, MSN
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
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
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
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
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Special considerations
Maria Carmela L. Domocmat, RN, MSN
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 clientMaria Carmela L. Domocmat, RN, MSN
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
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
Emotional
• Anxious
• Angry
• Depressed
• Manipulative• Manipulative
• Seductive
• When discussing sensitive issues
Maria Carmela L. Domocmat, RN, MSN
COMPLETE HEALTH HISTORY
Maria Carmela L. Domocmat, RN, MSN
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
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
Biographical data
• Name
• Age
• Religion
• Occupation • Occupation
Maria Carmela L. Domocmat, RN, MSN
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
History of Present Health concerns
• Mnemonic: COLDSPA, PQRST
Maria Carmela L. Domocmat, RN, MSN
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• 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 other symptom occur with it?
Maria Carmela L. Domocmat, RN, MSN
COLDSPA
CCCCharacter
Onset
LocationCOLDSPA Location
Duration
Severity
Pattern
Associated Factors
Maria Carmela L. Domocmat, RN, MSN
� P – provocative or palliative
� Q – quality or quantity
� R – region or radiation
� S - severity� S - severity
� T - timing
Maria Carmela L. Domocmat, RN, MSN
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
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
Review of body systems
• especially for current health problems
Maria Carmela L. Domocmat, RN, MSN
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
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
Lifestyle and health practices profile
• stress level and coping style, and
• environment.
Maria Carmela L. Domocmat, RN, MSN
Social data
• include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.
Maria Carmela L. Domocmat, RN, MSN
Psychological data
• information about the client’s emotional state.
Maria Carmela L. Domocmat, RN, MSN
Pattern of health care
• includes all health care resources: hospitals, clinics, health centers, family doctors.
Maria Carmela L. Domocmat, RN, MSN
Developmental level
Maria Carmela L. Domocmat, RN, MSN