Subjective Data Flashcards
3 stages of nursing interview
Introductory Stage, Working Stage, Termination Stage
Non-Verbal Communication
Appearance, Demeanor, Facial Expression, Attitude, Silence, Listening
Verbal Communication
Open-ended questions, Closed-ended questions, Laundry List, Rephrasing, Well placed phrases, Providing Information, Inferring
Communication To Avoid
Excessive or Insufficient Eye Contact, Distraction and Distance, Standing, Biased or Leading Questions, Rushing through the interview, Reading the Questions
Variations of Communication
Gerontologic, Cultural, Emotional
8 Sections of Health History
Biographical Data, Reasons for seeking health care, History of present illness/health concern, Past Health History, Family Health History, ROS (Review of systems), Lifestyle & Health Practices Profile, Developmental level
Role of The Nurse in Introductory Stage
Introduction of the nurse to the client , Explain the reason for taking notes, Ensure that the client is comfortable and has privacy, Develop trust and rapport
Role of the Nurse in Working Stage
Elicit the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, ROS, lifestyle and health practices and developmental level
Listens observes cues and uses critical nursing skills to interpret and validate information received
Role of the Nurse in Termination Stage
Summarizes and validates the information
Identifies and discussed possible plans to resolve the problem of the client
Makes sure to ask if anything else concerns the client and if there are further questions
Appearance
Professional in appearance
Wear comfortable, neat clothes
Wear your name tag
Neat hair and not in extreme style
Fingernails are short and neat
Jewelry minimal
Demeanor
No laughing out loud
Do not yell at your co-worker
Greet the client calmly and focus your full attention on her
Do not be overwhelmingly friendly or touchy
Maintain a professional distance
Facial Expression
Expression should be neutral and friendly
Appear understanding and concern
Attitude
Develop a non judgemental attitude
Do not act superior to the client or appear shocked, disgusted or surprised at what you are told
Do not try preaching to the client or imposing your own sense of ethics or morality
Avoid telling the patient that he or she is foolish or force guilt
Silence
Periods of silence allow the nurse and the client to reflect and organize thoughts
Listening
Most important skill learn and develop
Maintain good eye contact
Smile or display an open appropriate facial expression
Maintain an open arms and hands and lean forward
Avoid preconceived ideas or biases
Avoid crossing your arms, sitting back, tilting your head away from the client, thinking about other things or looking blank and inattentive
Keep an open mind
Use to elicit the client’s feelings and perceptions
Questions begin with HOW and WHAT
Open ended questions
Closed ended questions
Used to obtain facts and to focus on specific information
Questions begin with a WHEN and DID
Used to clarify or obtain more accurate information about issues
Rephrasing
An effective way to communicate during the interview
Helps to clarify information the client has stated
Enables the client reflect on what was said
Well-placed phrases
Properly used phrase will encourage the client to continue
Inferring
Will elicit more data or verify existing data
Be careful not to lead the client to answers that are not true
Assess hearing acuity
Gerontologic
Reluctance to reveal personal information
Cultural
Show respect to the client
Gerontologic
Seek help from experts if there is misunderstanding or difficulty in communicating with the client
Cultural
