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HEALTH ASSESSMENT LEC > Collecting Subjective Data > Flashcards

Collecting Subjective Data Flashcards

1
Q

Is the process of sharing information and
meaning, and of sending and receiving
messages.

A

COMMUNICATION

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2
Q

Messages can be:

A

o Verbal
o Nonverbal

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3
Q
  • More accurate than the verbal one.
  • Should coincide with the verbal data.
A

NONVERBAL MESSAGES

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4
Q

NONVERBAL BEHAVIOR

A

Vocal Cues or Paralinguistics
Personal Space
Action Cues or Kinetics
Touch
Object Cues

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5
Q

Quality of the voice and its inflections, tone,
intensity, and speed when speaking.

A

Vocal Cues or Paralinguistics

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6
Q

Vocal characteristics reflects:

A

▪ feelings
▪ Physiological or psychological
problems

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7
Q

Physical distance that needs to be
maintained for the person to feel
comfortable.

A

Personal Space

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8
Q

Proxemics

A

▪ Public Space – 12 feet of more
▪ Social-Consultative Space – 4-12 feet
▪ Personal distance – 18 inches – 4 ft
▪ Intimate – 0-18 inches

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9
Q
  • Means of communication.
  • Interpretation is culturally prescribed.
  • Gaining patient’s trust:
    ➢ helps obtain an accurate,
    comprehensive health history.
    ➢ makes physical assessment quicker
    and easier for both patient and nurse.
A

Touch

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10
Q

Dress and grooming as well as furnishings or possessions.

A

Object Cues

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11
Q
  • Body movements that convey a message.
  • May reflect feeling, mood, underlying
    physiologic and psychological problems.
A

Action Cues or Kinetics

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12
Q

COLLECTING OF DATA
TYPES OF DATA

A

SUBJECTIVE DATA
OBJECTIVE DATA

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13
Q
  • Covert and not measurable.
  • Referred to as Symptoms.
A

SUBJECTIVE DATA

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14
Q
  • Overt and measurable.
  • Referred to as Signs.
A

OBJECTIVE DATA

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15
Q

Gathering: SUBJECTIVE DATA

DATA SOURCES

A

Primary Data
Secondary Data

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16
Q

➢ Use of IPPA.
➢ Provides the objective database.

A

Physical Assessment

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17
Q

➢ Purposeful conversation between the nurse and the patient.

A

Interview

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18
Q

Purpose of Interview

A
  • Gather data
  • Establish rapport
  • Teach the patient
  • Health Promotion
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19
Q

use of interpersonal skills with empathy, acceptance, and recognition.

A

Therapeutic use of Self

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20
Q
  • Are nonverbal communication and listening
    skills
  • It will show full attention to what the client
    saying or doing
A

ATTENDING SKILLS

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21
Q

L.O.V.E.R.S.

A

Lean Forward
Open Stance
Verbal Output Modulated
Eye Contact
Relaxed Mode
Sit at 45 Degree Angle

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22
Q

TYPES OF QUESTIONS

A

Directive Interview
Nondirective Interview

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23
Q
  • interview controlled by the patient
A

Nondirective Interview

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24
Q
  • structured and controlled by the nurse
A

Directive Interview

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25
Q

PHASES OF INTERVIEW

A

Introductory Phase
Working Phase
Termination Phase

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26
Q

✓ Self-introduction
✓ Purpose of interview
✓ Time frame
✓ Confidentiality

A

INTRODUCTORY PHASE

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27
Q

✓ Data collection.
✓ Longest phase.

A

WORKING PHASE

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28
Q

✓ Summary.
✓ Follow-up plans

A

TERMINATION PHASE

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29
Q

INTERVIEW TECHNIQUES

A

Affirmation/Facilitation
Silence
Clarifying
Restating
Active Listening
Broad or General Openings
Reflection
Informing
Redirecting
Focusing
Sharing Perceptions
Sequencing Events
Suggesting
Presenting Reality
Summarizing

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30
Q

❑ Acknowledging patient’s responses.
❑ Nonverbal gestures, such as nodding or
sitting up and leaning forward, encourage
your patient to continue.

A

Affirmation/Facilitation

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31
Q

❑ Periods of silence allow patient to collect her
or his thoughts before responding and help
prevent hasty responses that may be
inaccurate. Silence also gives nurse more
time to think and plan a response.

A

Silence

32
Q

❑ If the nurse is unsure or confused about what
the patient is saying, rephrase what she said, and then ask the patient to clarify.

A

Clarifying

33
Q

❑ Restating the patient’s main idea shows him
that you are listening, allows you to
acknowledge your patient’s feelings, and
encourages further discussion.
❑ It also helps clarify and validate what patient
has said and may help identify teaching
needs.

A

Restating

34
Q

❑ Pay attention, maintain eye contact, and
really listen to what patient tells the nurse
both verbally and nonverbally.
❑ Active listening conveys interest and
acceptance. If nurse is unsure or confused
about what the patient is saying, rephrase
what she said and then ask the patient to
clarify

A

Active Listening

35
Q

❑ This technique is effective when nurses want
to hear what is important to the patient.
❑ “What would you like to talk about?” If nurse
is unsure or confused about what the patient
is saying, rephrase what she said and then
ask the patient to clarify.

A

Broad or General Openings

36
Q

❑ Allows nurse to acknowledge patient’s
feelings, encouraging further discussion.
❑ When patient expresses a thought or feeling,
nurses echo it back, usually in the form of a
question.

A

Reflection

37
Q

❑ Giving information allows patient to be
involved in his or her healthcare decisions.

A

Informing

38
Q

❑ Redirecting the patient helps keep the communication goal directed. It is especially useful if your patient goes off on a tangent.

A

Redirecting

39
Q

❑ Focusing allows you to hone in on a specific
area, encouraging further discussion.

A

Focusing

40
Q

❑ With this technique, nurse give interpretation
of what has been said in order to clarify
things and prevent misunderstandings.

A

Sharing Perceptions

41
Q

❑ Presenting alternative ideas gives patient
options.
❑ This is particularly helpful if the patient is
having difficulty verbalizing his or her
feelings.

A

Suggesting

42
Q

❑ If patient seems to be exaggerating or
contradicting the facts, help her or him
reexamine what has already been said and
be more realistic.

A

Presenting Reality

43
Q

❑ Summarizing is useful at the conclusion of a
major section of the interview.
❑ It allows the patient to clarify any
misconceptions you may have.

A

Summarizing

44
Q

INTERVIEWING PITFALLS

A

LEADING
LETTING FAMILY MEMBERS ANSWER
ASKING MORE THAN ONE QUESTION AT A TIME
NOT ALLOWING ENOUGH RESPONSE TIME
USING MEDICAL JARGON
ASSUMING
TAKING PATIENT’S RESPONSE PERSONALLY
FALSE REASSURANCE
PERSISTENT QUESTIONING
CHANGING THE SUBJECT
JUMPING TO CONCLUSIONS

45
Q

❑ People will tell you what you want to hear.
So don’t lead the patient.
❑ Having him or her describe what is
happening in his or her own words is much
more helpful.

A

LEADING

46
Q

❑ You will learn a lot more by having the
patient describe things in her or his own
words.

A

LETTING FAMILY MEMBERS ANSWER

47
Q

❑ The patient may not know which one to
answer. Or the nurse may not be sure which question is being answered.

A

ASKING MORE THAN ONE QUESTION AT A
TIME

48
Q

❑ Give the patient time to think through his or
her answer. This is especially important with
older patients.

A

NOT ALLOWING ENOUGH RESPONSE TIME

49
Q

❑ Express your questions in lay terms to make
sure your patient understands you

A

USING MEDICAL JARGON

50
Q

❑ Assuming can lead to inaccurate
interpretations and incorrect conclusions.

A

ASSUMING

51
Q

❑ An angry or frustrated patient may verbally
attack the nurse or the healthcare facility.
❑ Realize that the patient is displacing her or
his feelings on you and using you as a
sounding board.

A

TAKING PATIENT’S RESPONSE PERSONALLY

52
Q

❑ Telling the patient that everything will be fine
is condescending. It may not be.

A

FALSE REASSURANCE

53
Q

❑ Persistent or probing questions make your
patient uncomfortable.
❑ Remember, the patient has a right to not
answer a question.

A

PERSISTENT QUESTIONING

54
Q

❑ Some nurses change the subject when the
interview is making them uncomfortable.
❑ This is not very helpful for the patient.

A

CHANGING THE SUBJECT

55
Q

❑ Make sure all the facts have been gathered
before drawing conclusions.

A

JUMPING TO CONCLUSIONS

56
Q

❑ Provides a holistic, qualitative picture of the patient.

A

HEALTH HISTORY

57
Q

PURPOSES OF HEALTH HISTORY

A
  • Provide subjective database.
  • Identify patient strengths
  • Identify health problems
  • Identify supports
  • Identify teaching, discharge, and
    referral needs.
58
Q

cause
-preexisting medical conditions
-plan for the health problem

A

MEDICAL HISTORY

59
Q

Effect
- health and life effects
-strengths and support
-coping strategies

A

NURSING HISTORY

60
Q

HEALTH HISTORY TYPES

A

FOCUSED
COMPREHENSIVE

61
Q

✓ Name
✓ Address and Phone Number
✓ Age and birth date
✓ Birthplace
✓ Gender
✓ Marital Status
✓ Race
✓ Religion
✓ Educational Level
✓ Occupation
✓ Contact Person

A

Biographical Data

62
Q

It is not a diagnostic statement. Avoid translating it into medical terms.

A

chief complaint

63
Q

▪ Usual health status
▪ Any major health problems
▪ Usual patterns of healthcare
▪ Health concerns

A

Current Health Status

64
Q

Current Health Status (PQRST)

A
  • Precipitating/ Palliative Factors
  • Quality / Quantity
  • Region / Radiation / Related Symptoms
  • Severity
  • Timing
65
Q

▪ What were you doing when the problem
started?
▪ Does anything make it better, such as
medications, or certain positions?
▪ Does anything make it worse, such as
movement or breathing?

A

Precipitating/ Palliative Factors

66
Q

▪ Can you describe the symptom?
▪ What does it feel like, look like, or sound
like?
▪ How often are you experiencing it?
▪ To what degree does this problem affect
your ability to perform your ADL?

A

Quality / Quantity

67
Q

▪ Can you point where the problem is?
▪ Does it occur or spread anywhere else?
▪ Do you have any other symptoms?

A

Region / Radiation / Related Symptoms

68
Q

▪ Is the symptom, mild, moderate, or severe?
▪ Grade it on a scale of 0 to 10.

A

Severity

69
Q

▪ When did the symptom start?
▪ How often does it occur?
▪ How long does it last?

A

Timing

70
Q

▪ Prescriptions, OTC, herbal remedies
▪ Vitamins, birth control pills
▪ Dose and schedule
▪ Adverse reactions of medications
▪ Evaluation of medications taken

A

Medications

71
Q

✓ Identify health factors from the past that
have a direct relationship to patient’s current
health status.
✓ Identifies any chronic preexisting health
problems.
▪ Childhood illnesses
▪ Hospitalizations
▪ Surgeries
▪ Serious injuries
▪ Serious/Chronic illness
▪ Immunizations
▪ Allergies
▪ Medications
▪ Recent travel

A

Past Health History

72
Q

History of Present Illness

A

Well person
Ill person

73
Q

short statement about general
state of health.

A

WELL PERSON

74
Q

a chronological record of the
reason for seeking care, from the time the symptom first started until now.

A

ILL PERSON

75
Q

❑ Provides clues to genetically linked or familial diseases that may be risk factors for the patient.

A

Family History

76
Q

❑ Focuses on health promotion, protective
patterns, and roles and relationships.

A

Psychosocial Profile

77
Q

❖ Litany of questions specific to each body
system.
❖ Questions are about most frequently
occurring symptoms related to each system.

A

Review of Systems

HEALTH ASSESSMENT LEC (8 decks)

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