question

components of subjective data

answer

sensations, symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information

question

phases of the interview

answer

1)pre-introductory 2)introductory 3)working 4)summary and closing

question

pre-introductory phase

answer

-first phase of interview -nurse reviews medical record if available

question

introductory phase

answer

-second phase of interview -introductions, explanation of the purpose of the interview, assure client of confidentiality, make client comfortable (physically and emotionally), give client privacy, develop trust and rapport with client

question

working phase

answer

-third phase of interview -bulk of the interview, seek information, nurse engages in active listening, observing cues, critical thinking to interpretation and validate information received from client, collaborate to identify problems and goals

question

summary and closing phase

answer

-fourth phase of interview -nurse summarizes information and validates problems and goals with client, identify and discuss possible plans to resolve problem, make sure there are no other client concerns or questions

question

primary source of biographical data

answer

patient

question

effective nonverbal communication

answer

1) appearance - should be professional in neat, comfortable clothes and lab coat or uniform 2) demeanor - be professional and poised, focus on the client, maintain professional distance 3) facial expression - neutral expression, show a smile or concern when appropriate 4) attitude - do not act superior, be nonjudgemental 5)silence - allows you and client to reflect and organize thoughts 6) listening - show you are listening, eye contact, open body expression

question

effective verbal communication

answer

1) open-ended questions- typically begin with "how" or "what"; used to elicit client's feelings/perceptions 2) closed-ended questions - typically begin with "when" or "did"; client can respond with one or two words 3) laundry list - give them list of words to choose from 4) rephrasing - helps to clarify information 5) well-placed phrases - encourages client verbalization by letting them know you are listening "um-hum", "yes", "i agree" 6) inferring - do not lead the question, use same terms thst client uses, this helps to elicit most accurate data from client 7) providing information - answer every question and concern as thoroughly as possible, if unsure of answer explain to the client that you will find the answer for them

question

nonverbal communication to avoid

answer

1) excessive or insufficient eye contact 2) distraction and distance -do not appear to be mentally distant, avoid being more than 2 to 3 feet away from client during interview, client is main focus 3) standing - always sit when performing the interview

question

verbal communication to avoid

answer

1) biased or leading questions - can cause untrue answers 2) rushing through the interview - taking time shows you are concerned with their health 3) reading the questions

question

special condiserations during the interview

answer

1)gerontologic variations - hearing acuity, face them when you speak, eastablish and maintain trust, privacy, and partnership; they may require extra time 2)cultural variations - culture brokers are people who are familiar with the client's language, culture and related health care practices; variations in communication styles, willingness to openly express pain/distress, use and meaning of nonverbal communication, disease/illness perception, family's role in decision making, use and meaning of nonverbal communication 3) emotional variations - fear, anxiety, anger, depression, sensitivity issues

question

biographical data includes

answer

name, address, phone, gender, provider of history (patient or other), birth date, place of birth, race/ethnic background, primary/secondary languages (read and spoken), marital status, religious practices, educational level, occupation, significant others/support persons (availability)

question

reasons for seeking health care

answer

-major health problem or concern -feelings about seeking health care -get this in the form of a direct quote, usually one statement

question

history of present illness (HPI)

answer

-use COLDSPA -ask tons of question

question

COLDSPA*

answer

-Character: how does it feel, look, smell, sound, etc? -Onset: when did it begin? is it worse, better, or same? -Location: where is it? does it radiate? -Duration: how long does it last? does it recur? -Severity: how bad is it on a scale of 1 to 10? -Pattern: what makes it better/worse? -Associated factors: what other symptoms do you have with it? can you continue normal activities?

question

Past Health History includes

answer

-problems at birth -childhood illnesses -immunizations to date -adult illnesses (physical, emotional, mental) -surgeries -accidents -prolonged pain or pain patterns -allergies -physical, emotional, social, or spiritual strengths/weaknesses

question

family health history includes

answer

-age of parents (living? deceased date?) -parents' illnesses and longevity -grandparents; illnesses and longevity -aunts' and uncles; age and illnesses and longevity -children's ages and illnesses or handicaps and longevity

question

review of skin, hair, and nails systems for current health problems

answer

color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff

question

review of head and neck systems for current health problems

answer

headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat

question

review of ear systems for current health problems

answer

pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness, drainage

question

review of eye systems for current health problems

answer

pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision

question

review of mouth, throat, nose, and sinus systems for current health problems

answer

mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds

question

review of thorax and lung systems for current health problems

answer

pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections

question

review of breasts and regional lymphatic systems for current health problems

answer

pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla

question

review of heart and neck vessels for current health problems

answer

chest pain or pressure, palpitations, edema, last blood pressure, last ECG

question

review of peripheral vascular systems for current health problems

answer

leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs

question

review of abdomen for current health problems

answer

pain, indigestion, difficulty swallowing, nausea and vomiting, gas, jaundice, hernias

question

review of male genitalia for current health problems

answer

painful urination, frequency or difficulty starting or maintaining urinary system, blood in urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or ejaculation, exposure to STIs

question

review of female genitalia for current health problems

answer

pelvis pain, voiding pain, sexual pain, voiding problems (dribbling, incontinence) age of menarche or menopause (date of last menstrual period), pregnancies and types of problems, abortions, STIs, HRT, birth control methods

question

review of anus, rectum, and prostate for current health problems

answer

pain, with defecation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool

question

review of musculoskeletal systems for current health problems

answer

pain, swelling, red, stiff joints, strength of extremities, abilities to care for self and work

question

review of neurological systems for current health problems

answer

mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading or learning

question

lifestyle and health practices questions for health history

answer

description fo typical day, nutrition and weight management, 24 hour dietary intake (food and liquids), who purchases and prepares meals, activities on a typical day, exercise habits and patterns, sleep and rest habits and patterns, use of medications and other substances, self-concept, self-care responsibilities, social activities for fun and relaxation, social activities contributing to society, relationships with family/SOs/pets, values/religious affiliation, past/current/future education plans, type of work, level of job satisfaction, work stressors, finances, stressors in life, coping strategies uses, residency, types of environment, neighborhood, environmental risks

question

developmental level for health history

answer

-trust vs mistrust (0-1) hope -autonomy vs shame (1-3) will -initiative vs guilt (3-6) purpose -industry vs inferiority (6-12) competence -identity vs confusion (12-19) fidelity -young adult (20-25): intimacy vs. isolation, love -middlescent (26-64): generativity vs. stagnation, care -older adult (65 - death): ego integrity vs. despair, wisdom

question

tips for working with interpreteres *

answer

1) help the interpreter prepare and understand what needs to be done ahead of time 2)remember, the interpreter is the "communication bridge"and not the "content expert" 3)be patient. The interpreter's timing may not match that of others involved 4)speak slowly and clearly 5) pause every few sentences so the interpreter can translate your information 6) give the family and the interpreter a break 7) express the information in two to three different ways if needed 8) use an interpreter to help ensure that the family can read and understand translated written materials 9) avoid side conversations during sessions 10) remember, just because someone speaks another language doesn't mean that he or she will make a good interpreter 11)do not use children as interpreters

question

interacting with an anxious client

answer

-provide client with simple, organized information in a structured format -explain who you are, along with your role and purpose -ask simple, concise questions, ask why they feel anxious -avoid becoming anxious like the client -do not hurry, and decrease any external stimuli

question

interacting with an angry client

answer

-approach this client in a calm, reassuring, in-control manner. -allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client -obtain help from other health care professionals as needed -avoid arguing and facilitate personal space so that the client does not feel threatened or centered

question

interacting with a depressed client

answer

-express interest in and understanding of the client and respond in a neutral manner -do not try to communicate in an upbeat, encouraging manner. This will not help the depressed client

question

interacting with a manipulative client*

answer

-provide structure and set limits -differentiate between manipulations and a reasonable request -if you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues

question

interacting with a seductive client*

answer

-set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors -encourage client to use more appropriate methods of coping in relating to others

question

when discussing sensitive issues (ex: sexuality, dying, spirituality)*

answer

-first, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone -ask simple questions in a nonjudgmental manner and normalize things -allow time for ventilation of client's feelings as needed -if you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed

question

stanford sleepiness scale*

answer

-quick way to assess how alert you are feeling. -during the day ideal rating is 1 -if score is greater than 3 during a time when you should be alert, you may have a serious sleep debt

question

two peak time of alertness during the day*

answer

9 am and 9 pm

question

time of day alertness is at its lowest *

answer

3 pm

question

degree of sleepiness scal ratings*

answer

1 - feeling, active, vital, alert, or wide awake 2 - functioning at high levels, but not at peak; able to concentrate 3 - awake, but relaxed; responsive but not fully alert 4 - somewhat foggy, let down 5 - foggy; losing interest in remaining awake; slowed down 6 - sleepy, woozy, fighting sleep; prefer to lie down 7 - no longer fighting sleep, sleep onset soon; having dream-like thoughts X - asleep

Ch 2 Subjective Data (Nursing Assessment) – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards