gathering subjective data

Collection of subjective data

Maria Carmela L. Domocmat, RN, MSN

Subjective data
are data that are elicited and verified only by the
client
obtained through interviewing


consist of:
• sensations or symptoms (such as pain, hunger)
• preferences
• feelings (such as happiness or sadness)
• beliefs
• perceptions
• values
• desires
• Ideas
• personal information

• Skills needed to obtain data
– Interview and therapies communication skills
– Caring ability and empathy
– Listening skills


– helps provide the following data
• clues to possible physiologic, psychological, and
sociological problems
• reveal a client’s risk for a problem as well as areas of
strengths for the client


Complete Health History
– Biographical data
– Reasons for seeking health care
– History of Present Health concerns
– Past health history
– Family health history
– Review of body systems (especially for current
health problems)
– Lifestyle and health practices profile
– Developmental level

NURSING INTERVIEW


Nursing Interview
• a communication process that focuses on:
– establishing rapport and a trusting relationship with
the client to elicit accurate and meaningful
information
– gathering information on the client’s developmental,
psychological, sociocultural, and spiritual statuses to
identify deviations that can be treated with nursing
and collaborative interventions or strengths that can
be enhanced with nurse-client collaboration


Phases of the interview
• Phase I: Preinteraction
• Phase II: Introductory Phase
• Phase III: Working phase
• Phase IV: Summary and Closing Phase


Preinteraction
Gather data from medical records, other health
personnel
Review relevant literature
Plan the setting and time for the initial interview


Introductory Phase
Establish a nurse-client relationship/ rapport
Describe the purpose of the interview
Assure the client that the confidential data will
remain confidential
Make sure the client is comfortable (physically
and emotionally) and has privacy


Working phase
Interview the client about his health history
Nurse and client collaborate to identify the
client’s problems and goals.
Use information to plan the physical
examination


Summary and Closing Phase
Summarize information obtained and validates
problems and goals with the client
Identify possible plans to resolve the problem
(nursing diagnoses and collaborative problems) with
the client.
Ask if anything else concerns the client and if there
are any further questions
Document health history data
Validate the data with secondary sources if
necessary

COMMUNICATION DURING
INTERVIEW

Communication during interview
• Nonverbal communication
• Verbal communication



– Appearance:
– Demeanor
– Facial expression
– Attitude
– Silence
– Listening



– Appearance:
• ensure that your appearance is professional
• Comfortable, neat clothes
• Hair, nail, jewelry
– Demeanor
• Be professional
• Maintain professional distance



– Facial expression
• Keep expression neutral and friendly
• Use right expression at the right time
– Attitude
• Nonjudgmental attitude
• Do not preach to the client or impose your own sense of
ethics



– Silence
• Periods of silence allow you and the client to
reflect and organize thoughts, which facilitates
more accurate reporting and data collection
– Listening
• Most important skill to learn
• Maintain good eye contact, smile or display open,
appropriate facial expression, maintain open body
position

Verbal communication
• Open-ended questions
• Closed-ended questions
• Laundry list
• Rephrasing
• Well-placed phrases
• Inferring
• Providing information


• Open-ended questions
– “What”
– “How”

• Closed-ended questions


• Laundry list
– Provide a choice of words to choose from in
describing symptoms, conditions, or feelings
– “Is the pain severe, dull, sharp, mild, cutting, or
piercing?”
– “Does the pain occur once every year, day, month,
or hour?”


• Rephrasing
– Helps clarify information stated
– Enables nurse and the client to reflect on what was
said
– Ex: Mr. G tells you that he has been really tired and
nauseated for two months and that he is really scared
because he fears that he has some horrible disease.
– Paraphrase by saying, “You are thinking you have
serious illness?”

• Well-placed phrases
– Ex: “um-hum,” “Yes,” “I agree”
• Inferring
• Providing information


Let’s practice


Practice making open-ended questions

Restate each question below so it’s an open-ended
question
“Are you feeling better?”
“Did you like dinner?”
“Are you happy here?”
“Are you having pain?”


“Are you feeling better?” Tell me how you’re
feeling?
“Did you like dinner?” How was your dinner?

“Are you happy here?” How do you feel about
being here?
“Are you having pain?” Describe what you’re
feeling
Tell me how you’re
feeling.


Practice clarifying ideas by using reflection and
making open-ended questions

Reflection - restating what you hear
For each statement below, write a reflective
statement ad an open-ended question hat would help
you to clarify what has been said.
“I’ve been sick off and on for a month.”
“Nothing ever goes right for me.”
“I seem to have pain in my side that comes and
goes.”
“I’ve had this funny feeling for a week.”


“I’ve been sick off and on “So, you’ve been sick off
for a month.” and on for a month.
What do you mean by
sick on and off?


“Nothing ever goes right “You feel like nothing
for me.” ever goes right for you.
What’s been happening


“I seem to have pain in “You have a pain on your
my side that comes and side that comes and
goes.” goes—can you explain
more?


“I’ve had this funny “You’ve had a funny
feeling for a week.” feeling for a week. What
do you mean by funny?


Test your knowledge of
communication techniques


Read each statement below and identify whether it is
an open-ended statement (O), a closed-ended
statement ©, a leading question (L), an exploratory
statement (E), or a supplementary phrase or
statement intended to help the person continue (S)


a) Are you afraid of dying?
b) Tell me when this first started
c) I see
d) You’re not still afraid to feed Hector, are you?
e) How do you think you’ll be doing this at home?
f) Do you have a history of hypertension in your
family?
g) And..?
h) You do want your family to visit, don’t you?


i. How do you feel about being here?
j. You don’t need more practice, do you?
k. Explain what you mean by a “long time”


a) Are you afraid of dying? a) C - closed-ended
b) Tell me when this first statement
started b) E - an exploratory
c) I see statement
c) S - a supplementary
phrase or statement
intended to help the
d) You’re not still afraid to
person continue
feed Hector, are you?
d) L - leading question
e) How do you think you’ll
be doing this at home? e) O - an open-ended
statement


f. Do you have a history of f) C - a closed-ended
hypertension in your statement
family? g) S - a supplementary
g. And..? phrase or statement
h. You do want your family intended to help the
to visit, don’t you? person continue
i. How do you feel about h) L - a leading question
being here? i) O - an open-ended
j. You don’t need more statement
practice, do you? j) L - leading question
k. Explain what you mean k) E - an exploratory
by a “long time” statement


Special considerations


Gerontologic
• Assess hearing acuity
– Hearing loss normally occurs in age
– Undetected hearing loss is often misinterpreted as
mental slowness or confusion
• What to do:
– Speak slowly
– Face the client at all times during the interview
– Position yourself so that you are speaking on the
side of the client that has the ear with better acuity
– Do no yell at the clientDomocmat, RN, MSN
Maria Carmela L.

Gerontologic
• Do not talk down to the elderly – being older
physically does not mean the client is slower
mentally
• Show respect
• If client is mentally confused or forgetful, it is
important to have SO present to clarify the data


Cultural
• Be aware of the possible variations in
communication styles
• If difficulty in communication – seek help from
“culture broker” or culture expert.


Emotional
• Anxious
• Angry
• Depressed
• Manipulative
• Seductive
• When discussing sensitive issues


COMPLETE HEALTH HISTORY


Health History
• Biographical data
• Reasons for seeking health care
• History of present health concern
• Past health history
• Family health history


Health History
• Review of body systems (especially for current
health problems)
• Lifestyle and health practices profile
• Developmental level


Biographical data
• Name
• Age
• Religion
• Occupation


Reasons for seeking health care
• “What is your major health problem or concerns
at this time?” –chief complaints
• “How do you feel about having to seek health
care?” -encourage the client to discuss fears or
other feelings about having to see a health care
provider.


History of Present Health concerns
• Mnemonic: COLDSPA, PQRST


History of Present Health concerns
• Character: describe the sign or symptom; how
does it feel, look, sound, smell, and so forth?
• Onset: when did it begin?
• Location: where is it?, does it radiate
• Duration: how long does it last?
• Severity: how bad is it?
• Pattern: what makes it better? what makes it
worse?
• Associated Factors: what otherMSN
Maria Carmela L. Domocmat, RN, symptom occur

with it?

Character
Onset
COLDSPA Location
Duration
Severity
Pattern
Associated Factors

P – provocative or palliative
Q – quality or quantity
R – region or radiation
S - severity
T - timing


Past health history
• Birth • surgeries
• growth & development• pregnancies
• childhood diseases • births
• immunizations • previous accidents
• allergies • injuries
• previous health • pain experiences
problems • emotional or
• hospitalizations psychiatric problems

Family health history

• reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
• Use genogram


Review of body systems
• especially for current health problems


Lifestyle and health practices profile
Include:
• nutritional habits, activity and exercise patterns,
• sleep and rest patterns,
• use of medications, & substances


• self-concept & self-care activities
• social and community activities,
• relationships,
• values and belief system,
• education and work,


• stress level and coping style, and
• environment.


Social data
• include family relationships, ethnic and
educational background, economic status, home
and neighborhood conditions.


Psychological data
• information about the client’s emotional state.


Pattern of health care
• includes all health care resources: hospitals,
clinics, health centers, family doctors.


Developmental level


gathering subjective data

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