Subjective Data

• Subjective data includes sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information
• Interviewing is a communication process with two focuses: establishing rapport and a trusting relationship with the client and gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual status
• • Summary and Closing Phase: Nurse summarizes information obtained, validates problems and goals with the client, and discusses possible plans to resolve issues
• Phases of the interview:

  • Pre-Introductory Phase: Nurse reviews the medical record before meeting with the client, which may reveal past health history and reason for seeking health care
  • Introductory Phase: Nurse introduces herself, explains the purpose of the interview, ensures client comfort, and develops trust and rapport
  • Working Phase: Nurse elicits client's comments about major biographical data, reasons for seeking care, health concerns, history, family history, lifestyle, and health practices
• Communication during the interview:

  • Nonverbal communication is as important as verbal communication
  • Appearance, demeanor, posture, facial expressions, and attitude influence how the client perceives questions
  • Verbal communication goal is to elicit data about the client's health status
  • Nonverbal communication to avoid includes excessive or insufficient eye contact, distraction, distance, and standing while the client is seated
• • Verbal communication techniques include open-ended questions, close-ended questions, laundry list approach, rephrasing, well-placed phrases, inferring, and providing information
  • Verbal communication to avoid includes biased or leading questions and rushing through the interview
• Special Considerations during the interview:

  • Avoid rushing the client during the interview process
  • Rushing through the interview may lead the client to believe their individual situation is of little concern
  • Taking time with clients shows concern about their health and helps them to open up
  • Rushing someone through the interview process causes important information to be left out of the health history
  • Clients may try to hurry the interview by providing abbreviated or incomplete answers to questions
• Gerontologic Variations in Communication:

  • Assess hearing acuity in older clients as hearing loss occurs with age
  • Speak slowly and face the client at all times during the interview
  • Position yourself so that you are speaking on the side of the client with better ear acuity
  • Older clients may have more health concerns and seek healthcare more often
  • Establishing trust, privacy, and partnership with older clients is important
  • Speak clearly and use straightforward language during the interview
  • Ask questions in simple terms without talking down to the client
• • Have a significant other present during the interview if the client is mentally confused or forgetful
• Cultural Variations in Communication:

  • Seek help from a culture broker if there are misunderstandings or difficulties in communication
  • Use an interpreter if the client does not speak your language
  • Consider the relationship of the interpreter to the client for effective communication
  • Communication through pictures may be helpful with some clients
  • Variations in communication styles include reluctance to reveal personal information, willingness to express emotional distress, and variation in nonverbal communication
• Emotional Variations in Communication:

  • Clients may not always be calm, friendly, or eager to participate in the interview process
  • Clients may be scared, anxious, angry, or depressed during the interview
  • Provide structured information for anxious clients and approach angry clients in a calm manner
  • Express interest and understanding for depressed clients
  • Set limits for manipulative and seductive clients
  • Discuss sensitive issues in a nonjudgmental manner and make referrals as needed
• Complete Health History:

  • Provides the foundation for identifying nursing problems and focusing the physical examination
  • Assists in identifying areas of strength and limitation in the individual's lifestyle and health status
  • Provides specific cues to health problems most apparent to the client
  • Modified or shortened when necessary
• 8 Sections of Health History:

  • Biographical data
  • Reasons for seeking health care
  • History of present health concern
  • Personal health history
  • Family health history
  • Review of Systems for Current Health problems
  • Lifestyle and health practices profile
  • Developmental level
• Collecting Client Information:

  • Primary source: the client
  • Secondary sources: significant others or other client's medical record
  • Validation of information by a secondary source may be helpful
  • Client's immediate family or caregiver may be a more accurate source of information in some cases
• Determining Client's Culture and Ethnicity:

  • Collect data about date and place of birth, nationality or ethnicity, marital status, religious or spiritual practices, and languages spoken
  • Information helps examine special needs and beliefs that may affect the client or family's health care
  • Primary language is usually the one spoken in the family during early childhood
  • Educational level, occupation, and working status assist in tailoring questions to the client's level of understanding
• Information about the client's age, education, occupation, and working status helps tailor questions to the client's level of understanding
• Identifying who lives with the client and significant others indicates the availability of potential caregivers and support people
• Absence of support people may indicate the need for finding external sources of support
• "What is your major health problem or concern at this time?" assists the client in focusing on the most significant health concern
• Primary care providers call this the client's chief complaint (cc)
• "How do you feel about having to seek health care?" encourages the client to discuss fears and feelings about seeking health care
• May draw out concerns beyond a physical complaint and address stress or lifestyle changes
• Encourage the client to explain the health problem or symptom in detail, focusing on onset, progression, duration, signs, symptoms, and perceived causes
• Ask the client to evaluate what makes the problem worse, what makes it better, treatments tried, impact on daily life, recovery expectations, and ability to provide self-care
• Ask about childhood illnesses, immunizations, adult illnesses, surgeries, accidents, pain episodes, allergies, and medication use
• Information assists in identifying risk factors from previous health problems
• Include as many genetic relatives as the client can recall in the family health history
• Drawing a genogram helps organize and illustrate the client's family history
• Review of Systems for current health problems involves addressing each body system and asking specific questions to elicit further details
• Document the client's descriptions of health status for each body system
• Lifestyle and Health Practices Profile includes assessing human responses, nutritional habits, activity patterns, sleep, self-concept, social activities, relationships, values, education, work, stress levels, coping styles, and environment
• Use open-ended questions to promote dialogue with the client
• Description of a typical day, nutrition and weight management, activity level, exercise, sleep and rest, substance use, self-concept, self-care responsibilities, social activities, relationships, values, education, work, stress levels, coping styles, and environment are important areas to assess
• Objective Data includes information observed directly during interaction with the client and through physical assessment techniques
• Preparing for the examination involves ensuring a comfortable, private, quiet, well-lit environment with necessary equipment and proper hygiene practices
• Establish the nurse-client relationship before the physical examination takes place
• Before the physical examination takes place, it is important to:

  • Respect the client's desires and requests related to the physical examination
• Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings
• Palpation consists of using parts of the hand to touch and feel for different characteristics such as texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape, and degree of tenderness
• Three different parts of the hand are used during palpation:

  • Finger pads
  • Ulnar/palmar surface
  • Dorsal surface