Ch 2 Subjective Data (Nursing Assessment) Essay

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components of subjective data
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sensations, symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information
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phases of the interview
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1)pre-introductory 2)introductory 3)working 4)summary and closing
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pre-introductory phase
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-first phase of interview -nurse reviews medical record if available
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introductory phase
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-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
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working phase
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-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
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summary and closing phase
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-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
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primary source of biographical data
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patient
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effective nonverbal communication
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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
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effective verbal communication
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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
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nonverbal communication to avoid
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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
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verbal communication to avoid
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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
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special condiserations during the interview
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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
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biographical data includes
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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)
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reasons for seeking health care
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-major health problem or concern -feelings about seeking health care -get this in the form of a direct quote, usually one statement
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history of present illness (HPI)
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-use COLDSPA -ask tons of question
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COLDSPA*
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-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?
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Past Health History includes
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-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
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family health history includes
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-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
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review of skin, hair, and nails systems for current health problems
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color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff
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review of head and neck systems for current health problems
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headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat
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review of ear systems for current health problems
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pain, ringing, buzzing, drainage, difficulty hearing, exposure to loud noises, dizziness, drainage
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review of eye systems for current health problems
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pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision
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review of mouth, throat, nose, and sinus systems for current health problems
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mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds
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review of thorax and lung systems for current health problems
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pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections
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review of breasts and regional lymphatic systems for current health problems
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pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla
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review of heart and neck vessels for current health problems
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chest pain or pressure, palpitations, edema, last blood pressure, last ECG
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review of peripheral vascular systems for current health problems
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leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs
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review of abdomen for current health problems
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pain, indigestion, difficulty swallowing, nausea and vomiting, gas, jaundice, hernias
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review of male genitalia for current health problems
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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
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review of female genitalia for current health problems
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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
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review of anus, rectum, and prostate for current health problems
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pain, with defecation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool
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review of musculoskeletal systems for current health problems
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pain, swelling, red, stiff joints, strength of extremities, abilities to care for self and work
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review of neurological systems for current health problems
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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
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lifestyle and health practices questions for health history
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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
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developmental level for health history
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-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
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tips for working with interpreteres *
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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
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interacting with an anxious client
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-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
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interacting with an angry client
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-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
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interacting with a depressed client
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-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
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interacting with a manipulative client*
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-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
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interacting with a seductive client*
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-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
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when discussing sensitive issues (ex: sexuality, dying, spirituality)*
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-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
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stanford sleepiness scale*
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-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
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two peak time of alertness during the day*
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9 am and 9 pm
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time of day alertness is at its lowest *
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3 pm
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degree of sleepiness scal ratings*
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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

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