SUBJECTIVE DATA (HAS)

• SUBJECTIVE DATA - integral part of interviewing the client to obtain a nursing health history.
• SUBJECTIVE DATA - symptoms or covert data.
• SUBJECTIVE DATA - can be elicited and verified only by the client.
• SUBJECTIVE DATA - provide clues to possible psychological, physiological and sociological problems.
• INTERVIEWING - obtaining a valid nursing health history requires professional, interpersonal and interviewing skills.
• INTERVIEWING - establish rapport or trust relationship with the client to get an accurate and meaningful information.
• PRE-INTRODUCTORY PHASE - nurse review the medical record before meeting with the client, knowing biographical info of client may assist the nurse with conducting the interview.
• INTRODUCTORY PHASE - introduce, and nurse explains the procedure and discusses the types of questions will be asked, and assure the client that all confidential information will remain confidential.
• WORKING PHASE - the longest phase, nurse elicit the client comments about major data, reasons of seeking care, history of present health concern, past health history or family history.
• WORKING PHASE - nurse listens and observe cues and nurse and client elaborate to identify the client problems and goals.
• SUMMARY OR CLOSING PHASE - nurse summarizes the obtained information and validates problems and goals with the client, identifies and discusses possible plans to resolve the problem.
• APPEARANCE - ensure that your appearance is professional.
• DEMEANOR - display poise, greet the client calmly, do not touchy.
• FACIAL EXPRESSION - keep your expression neutral and friendly.
• ATTITUDE - non judgemental attitude, do not act as superior to your client.
• SILENCE - allow you and client reflect and organize thoughts which facilitated more accurate reporting data collection.
• LISTENING - listen effectively, maintain good eye contact, smile or display appropiate facial expressions.
• VERBAL COMMUNICATIONS

  • OPEN ENDED QUESTIONS - used to elicit client feelings and perceptions, begin with the words "how" and "what"
• VERBAL COMMUNICATIONS

  • CLOSE ENDED QUESTIONS - answerable by yes or no.
• VERBAL COMMUNICATIONS

  • LAUNDRY LIST - DESCRIPTIVE WORDS, provide client with a list of words to choose from describing.
• VERBAL COMMUNICATIONS

  • REPHRASING - provided an effective way to communicate during interview, helps you clarify information the client has stated.
• VERBAL COMMUNICATIONS

  • INFERRING - client tells you and what you observe in the client behavior may elicit more data and verifying existing data.
• VERBAL COMMUNICATIONS

  • PROVIDING INFORMATION - important thing to do is to provide the client information concerns arise, make sure to answer every questions.
• SPECIAL CONSIDERATION

  • GERONTOLOGIC VARIATIONS - age affects and commonly slows body systems to varying degrees.
• SPECIAL CONSIDERATION

  • CULTURAL VARIATIONS - be aware of possible variation in communication styles and the clients.
• SPECIAL CONSIDERATION

  • EMOTIONAL VARIATIONS - Clients emotions may vary for a number of reasons, scared, anxious, about their health and angry that they are sick or depressed about their health or life events.
• COMPLETE HEALTH HISTORY - provides the foundation for clinical judgements in identifying nursing problems, where to focus and areas where a more detailed physical examination may be needed.
• COLDSPA

  • CHARACTER
  • ONSET
  • LOCATION
  • DURATION
  • SEVERITY
  • PATTERN
  • ASSOCIATED FACTORS
• PQRST

  • PROVOCATIVE OR PALLIATIVE 


  what provokes or relieve the pain?
• PQRST

  • QUALITY


  describe the character of the pain
• PQRST

  • RADIATES 


  is the pain localized or does it spread to other areas?
• SUBJECTIVE DATA -


  a key step of nursing health assessment, consist of information elicited and verified only by the client.