gathering subjective data

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

� 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

• Skills needed to obtain data

– Interview and therapies communication skills

– Caring ability and empathy

– Listening skills – Listening skills

– 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

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

NURSING INTERVIEW

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

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

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

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

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

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

Communication during interview

• Nonverbal communication

• Verbal communication

– Appearance:

– Demeanor

– Facial expression– Facial expression

– Attitude

– Silence

– Listening

– Appearance:

• ensure that your appearance is professional

• Comfortable, neat clothes• Comfortable, neat clothes

• Hair, nail, jewelry

– Demeanor

• Be professional

• Maintain professional distance

– 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

– 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

• Open-ended questions

– “What”

– “How”

• Closed-ended questions

• 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?”

• 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?”

• Well-placed phrases

– Ex: “um-hum,” “Yes,” “I agree”

• Inferring

• Providing information• Providing information

Let’s practice

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?”

� “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.

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.”

� “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?

� “Nothing ever goes right for me.”

� “You feel like nothing ever goes right for you. What’s been happening

� “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?

� “I’ve had this funny feeling for a week.”

� “You’ve had a funny feeling for a week. What do you mean by funny?

Test your knowledge of communication techniques

� 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)

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?

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”

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

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

Special considerations

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

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.

Emotional

• Anxious

• Angry

• Depressed

• Manipulative• Manipulative

• Seductive

• When discussing sensitive issues

COMPLETE HEALTH HISTORY

Health History• Biographical data

• Reasons for seeking health care

• History of present health concern

• Past health history• Past health history

• Family health history

Health History• Review of body systems (especially for current

health problems)

• Lifestyle and health practices profile

• Developmental level• Developmental level

Biographical data

• Name

• Age

• Religion

• Occupation • Occupation

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.

History of Present Health concerns

• Mnemonic: COLDSPA, PQRST

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?

COLDSPA

CCCCharacter

LocationCOLDSPA Location

Duration

Severity

Pattern

Associated Factors

� P – provocative or palliative

� Q – quality or quantity

� R – region or radiation

� S - severity� S - severity

� T - timing

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

Family health history

• reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).

• Use genogram• Use genogram

Review of body systems

• especially for current health problems

Lifestyle and health practices profile

Include:

• nutritional habits, activity and exercise patterns,

• sleep and rest patterns,

• use of medications, & substances• use of medications, & substances

• self-concept & self-care activities

• social and community activities,

• relationships,

• values and belief system, • values and belief system,

• education and work,

• stress level and coping style, and

• environment.

Social data

• include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.

Psychological data

• information about the client’s emotional state.

Pattern of health care

• includes all health care resources: hospitals, clinics, health centers, family doctors.

Developmental level

gathering subjective data

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