Collecting Subjective Data: The Interview and Health History Flashcards
The nursing interview has four basic phases:
pre-introductory,
introductory,
working,
summary/closing phases
phase: The nurse reviews the medical record before meeting with the client
pre-introductory
phase: After introducing herself to the client, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential
introductory
phase: The nurse makes sure that the client is comfortable (physically and emotionally) and
has privacy. Developing rapport
depends heavily on verbal and nonverbal communication on the part of the nurse
introductory
During this phase, the nurse elicits the client’s comments about major biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems (ROS) for current health problems, lifestyle and health practices, and developmental level.
working phase
the nurse summarizes information obtained during the working phase and validates problems and goals with the client. She also identifies and discusses possible plans to resolve the problem (client
concerns and collaborative problems) with the client. Finally, the nurse makes sure to ask if anything else concerns the client and if there are any further questions.
summary and closing phase
The client interview involves two types of communication—
nonverbal and verbal
First take care to ensure that your ?? is professional. The client is expecting to see a health professional; therefore, you should look the part
appearance
When you enter a room to interview a client, display poise. Focus on the client and the upcoming interview and assessment. Do not enter the room laughing loudly, yelling to a coworker, or muttering under your breath. It is best to maintain a professional
distance.
demeanor
often an overlooked aspect of communication. It often shows what you are truly thinking (regardless of what you are saying), monitor them closely
facial expressions
It means using the right expression at the right time.
displaying neutral expression
One of the most important nonverbal skills to develop as a health care professional is a ???. All clients should be accepted, regardless of beliefs, ethnicity, lifestyle, and health care practices.
nonjudgmental attitude
Five “A”s of Behavior Change:
Ask, Advise, Assess, Assist, and Arrange
allow you and the client to reflect and organize thoughts, which facilitate more accurate reporting and data collection.
silence
most important skill to learn and develop fully in order to collect
complete and valid data from your client.
listening
are used to elicit the client’s feelings and perceptions. They typically begin with the words “how” or “what.”
Open-ended questions
Use ??? to obtain facts and to focus on specific information. The client can respond with one or two words.
closed-ended questions
typically begin with the words “when” or “did.”
Closed-ended questions
approach: Another way to ask questions is to provide the client with a list of words to choose
from in describing symptoms, conditions, or feelings.
laundry list
??? information the client has provided is an effective way to communicate during the interview. This technique helps you to clarify information the client has stated; it also enables you and the client to reflect on what was said.
Rephrasing
The nurse can encourage client verbalization by using ??.
well-placed phrases
??? information from what the client tells you and what you observe in the client’s behavior may elicit more data or verify existing data.
Inferring information
Another important thing to do throughout the interview is to provide the client with
??? as questions and concerns arise.
information
Three variations in communication must be considered as you interview clients:
gerontologic, cultural, and emotional.
