chap 2 Flashcards
subjective data consists of
- sensations/symptoms
- feelings
- perceptions
- desires
- preferences
- beliefs
- ideas
- values
- personal info
health history
collection of info obtained from pt & other sources
data from health history is basis for
plan of care
interviewing
direct method of gathering info that allows for questions to adapt to responses
phases of interview
- introduction
- working
- summary & closing
preintroductory phase
- nurse reviews medical record
- may reveal past health history and reason for seeking care
introductory phase
- introduction
- purpose for interview
- discussing questions
- explain why taking notes
- confidential info
- verify client privacy
- develop trust
working phase
- biographical data
- reasons for care
- present health concern
- past health history
- family history
- review of body systems
- lifestyle/health practices
summary & closing phase
- summarize info
- validate problems and goals
- identify and discuss plans
- any other concerns
nonverbal communication
- appearance
- demeanor
- facial expression
- attitude
- silence
- listening
verbal communication
- open/closed ended questions
- laundry list
- rephrasing
- well placed phrases
- inferring
- providing info
nonverbal comm to avoid
- excessive/insufficient eye contact
- distraction and distance
- standing
verbal comm to avoid
- biased/leading question
- rushing
- reading the questions
special consideration
- gerontologic variations
- cultural variations
emotional variations
- depressed
- anxious
- angry
- seductive
- discussing sensitive issues
when talking about reasons for seeking care, ask which 2 questions?
- what is your major health concern at this time?
- how do you feel about having to seek health care?
braden scale
tool for predicting ulcer risk
five A’s of behavioral change
- ask
- advise
- assess
- assist
- arrange
rephrasing
helps clarify info client has stated
chief complaint
brief statement describing symptoms, problem, diagnosis, or condition that is reason for care
lifestyle and health practices
- typical day
- nutrition
- 24 hour dietary intake
- who purchases/cooks food
- activity on typical day
- rest/sleep habits
- medication and substance abuse
- self concept
- social activities
- relationships
- values/belief system
- past, present, future education/work
- stress levels
- environment
additional assessments
- functional
- mental
- cultural
- nutritional
- skin
- age specific
- disease specific
in review of body systems you should only include what info
client’s subjective information
review of body systems
- each body system is addressed
- client asked specific questions
