Term
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Definition
*Consists of
-Sensations and Symptoms
-Feelings
-Perceptions
-Desires
-Preferences
-Personal information
-Ideas
-Beliefs or values
*Data elicited and verified by the patient
*Information obtained through interviewing
*Nurse unaware of symptoms unless patient describes the symptoms |
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Term
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Definition
*Need to be professional and interpersonal
*It consists of a communication process
*Interview process has 2 focuses:
1. Establish rapport and trusting relationship with patient to elicit accurate and meaningful information
2. Gather information of the patient's psychological, physiological, sociocultural, and spiritual status |
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Term
| Three Phases of the Interview |
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Definition
1. Introductory
2. Working
3. Summary and Closing |
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Term
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Definition
*Introduce yourself to patient
*Establish rapport and trust (look professional)
*Explain the purpose of the interview
-Tell them how long it's going to take, sit a patient's level, maintain good eye contact, be friendly
*Discuss the types of questions that will be asked (personal and sensitive)
*Explain the reason for taking notes
-To make sure to obtain accurate information
*Assure client that confidential information will remain confidential (Only shared with healthcare team that must know to provide care)
*Making sure that the client is comfortable and has privacy |
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Term
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Definition
*Gain information on:
-Biographical data
-Reason for seeking care
-History of present health concern
-Past health history
-Review of body systems for current problems
-Lifestyle and health practices
-Developmental level
*Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client
*Collaborating with the client to identify the client's problems and goals |
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Term
| Summary and Closing Phase |
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Definition
*Summarizing information obtained during the working phase
*Validating problems and goals with client
*Identifying and discussing possible plans to resolve the problem with the client
*Making sure to ask if anything else concerns the client and if there are any further questions |
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Term
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Definition
*Appearance (Be professional/Uniform/Name tag)
*Demeanor (Don't enter laughing)
*Facial Expression (Be neutral)
*Silence
*Listening
*Posture
*Attitude (nonjudgemental, don't preach)
*Avoid:
-Excessive or insufficient eye contact
-Distraction and distance- don't be occupied
-Standing- puts you at different levels |
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Term
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Definition
*Open-Ended Questions
-Used to obtain client's feelings or perceptions
- "How have you been feeling lately?"
*Close-Ended Questions (Yes or No)
-Used to obtain facts
-"Do you smoke?"
*Laundry List
-Providing client with list of words to answer questions
- "Is your pain sharp, dull, or piercing?"
*Rephrasing
-Helps to clarify
-Allows your patient to reflect
*Inferring
-Helps obtain more accurate information
-If client says having pain in her stomach, but is holding right abdomen
*Well placed phrases
-Use phrases such as "yes" or "I agree"
*Providing Information
-During interview provide info to client
-If you don't know- reassure you will find out
-Helps decrease anxiety when patient is informed
*Avoid:
-Biased or leading questions ("So are you having pain?")
-Rushing
-Reading the questions |
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Term
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Definition
*Gerontologic Variations
-Hearing acuity
-Don't assume they're sick
-Vulnerable and scared
-Speak clearly, and avoid medical jargon
*Cultural Variations
-Do they speak English- Interpreter
-Eye contact rude in some cultures
*Emotional Variations
-Hard to interview patient who is crying- get needed information and come back to complete when more emotionally stable |
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Term
| Interacting With Anxious Client |
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Definition
*Provide client with simple organized information in a structured format
*Explain who you are and your role/purpose
*Ask simple, concise questions
*Avoid becoming anxious
*Do not hurry
*Decrease external stimuli (family) |
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Term
| Interacting with and Angry Client |
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Definition
*Approach the client in a calm, reassuring, in-control manner
*Allow the client to vent feelings
*Avoid andy arguments with or touching client
*Obtain help from other health care professionals as needed
*Facilitate personal space so that the client does not feel threatened or concerned
*Listen to your gut |
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Term
| Interacting with a Depressed Client |
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Definition
*Express interest in an understanding of the client and respond in a neutral manner
*Take care not to communicate in an upbeat, encouraging manner
*Validate and empathize |
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Term
| Interacting with a Manipulative Client |
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Definition
*Provide structure and set limits
*Differentiate between manipulation and a reasonable request
*Obtain an objective opinion from other nursing colleagues
*Will want you to wait on them hand and foot |
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Term
| Interacting with a Seductive Client |
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Definition
*Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors
*Encourage client to use more appropriate methods of coping and relating to others
*If you don't feel safe, leave client
*Bring another nurse into the interview with you
*Can say, "I don't feel comfortable when you say that to me |
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Term
| Discussing Sensitive Issues |
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Definition
*Be aware of your own feelings and thoughts regarding dying, spirituality, and sexuality
*Ask simple questions in a nonjudgemental manner
*Allow time for ventilation of clients feelings as needed
*If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate |
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Term
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Definition
*Subjective Information
*Biographical data, history, etc. |
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Term
| History of Present Health Concern |
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Definition
*Use mnemonic COLDSPA to obtain essential information about present health concern
*Many different mneumonics used |
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Term
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Definition
*Character
*Onset
*Location
*Duration
*Severity
*Pattern
*Associated Factors |
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Term
| Past/Family Health History |
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Definition
*Assessing for genetic link w/ illness
*Include as many blood relatives as the patient can recall
*Make a genogram |
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Term
| Review of Body Systems (ROS) |
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Definition
*Ask specific questions about each body system to obtain more information
*Only obtain subjective information |
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Term
| Lifestyle and Health Practices |
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Definition
*Client's describe how they are managing their lives
*Includes:
-Description of typical day
-Nutrition and weight management
-Activity level and exercise
-Sleep and rest
-Medication and substance use
-Self-concept and self-care responsibilities
-Social activities
-Relationships
-Values and belief systems
-Education and Work
-Stress levels and coping styles
-Environment |
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