215- Ch. 2 Collecting Subjective Data: The Interview and Health History

Palpitation

Light- half inch, pulses/tenderness/surface skin texture/temperature/moisture Deep- 1-1 1/2inch, deep organs/structures covered by thick muscle Bimanual, 2 hands (breast/uterus/spleen), size/shape/consistency/mobility

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information. -The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes.

A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?

Relaxed -Facial expressions should be relaxed, caring, and interested. Facial expressions that are happy, inquisitive, or detached can interfere with the therapeutic communication process.

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client -To facilitate optimal eye contact, the nurse needs to be at eye level with the client. Those who stand while clients are in bed will be taller than clients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level with clients who are in bed during interviews.

What is objective data?

Something to measure, have to validate what they're telling you

What are the two types and sources of data?

Subjective and objective

When palpating with ulnar or palmar surface this allows to feel

Vibration, thrills, fremitus

What is a chief complaint?

What caused them to come here in the first place

Objective data

-gather equipment/prepare room/promote safety/adequate lighting/firm exam table, bed/beside table, tray to hold equipment

What are the challenges of subjective data?

Challenges- patient may be lying, could be changing they're story depending on who's around them (parents/partner in room)

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief -The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions.

What are the three methods of data collection?

Interview Observation Physical assessment

When palpating using dorsal (back) surface this allows to feel

Temperature

What is subjective data?

The story, what they're telling you, full of emotion/experience/perception

What is therapeutic communication?

Trying to understand what it is like for a patient but not having pity

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?" -To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?" -To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive.

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?

"Let me stress the importance of being medication adherent." -The termination phase of the interview contains a summary of important points such as the need to be medication adherent. Setting expectations is addressed in the introduction phase while expanding the client's story and negotiating a plan of care are completed during the interview's working phase.

A nurse has admitted a client to the medical unit and is describing the purpose for obtaining a comprehensive health history. Which of the following purposes should the nurse describe?

"This helps us have an appropriate focus for the physical examination." -The information gained in a comprehensive health history lays the groundwork for identifying client health problems that need further exploration and validation during the physical exam. It is one aspect of the client's health record and helps to provide some indication about possible risk factors for the client.

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history

"What is your major health concern at this time?" -Asking the question about the client's major health concern assists the client to focus on the most significant issues and answers the nurse's question "why are you here?" or "how can I help you?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?" -"What is your routine for checking your blood sugar these days?" is an open-ended question designed to elicit as much information as possible about how the client is monitoring blood sugar

Auscultation

*only ever comes before when examining abdomen -diaphragm, high-pitched sounds -bell, low-pitched sounds

Considerations for the interview

-age/developmental/cognitive/physical -individualized -safety *always start at that 5th grade level

The introductory phase of the interview should consist of

-explaining he purpose -discusses the type of questions -assurance of confidently -important to establish trust & rapport

When interacting with an angry client

-find out what they're angry about, listen, allow them to vent, do not argue with them, if escalating obtain help from other health care professionals, do not corner them, give them space *NEVER put the patient between you and the door

Problem solving invovles

-focuses on gathering in-depth data on specific problems -utilization of COLDSPA Mnemonic

What are the phases of the Interview phase?

1. Pre-introductory phase 2. Introductory phase 3. Working phase 4. Summary & closing phase

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question. -The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed. -The nurse can also say, "I want to make sure I take good care of this problem because it is very important. We may need to talk about the others at the next appointment. Is that OK with you?" This is a helpful technique that can help the nurse to change the subject, but at the same time, validate the client's concerns; this can provide more structure to the interview

What are the challenges and benefits of objective data?

Challenges- maybe thy don't want to remove their clothes, or they want a female or male instead, knowing how to do the skill, may not have enough time to do an in-depth examination Benefits- can get it quickly, no room for a patient to lie because it's what your see

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise. -Closing the door may help to limit background noise, making it easier for the client to hear.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview. -During the introductory phase, the nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client about the confidentiality of the information.

When palpating using finger pads this allows to feel

Fine discriminations: pulse, texture, size, consistency, shape

The working phase of the interview should consist of

Obtaining data

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this?

Summary -During the summary and closing, the nurse summarizes information obtained during the working phase and validates problems and goals with the client

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint -The chief complaint is the reason for the person seeking care.

A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse document this information in the comprehensive assessment?

review of systems -General information about the nose would be included within the review of systems. The past history and history of present illness identify major illnesses that have affected the client.

A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental?

"You must quit smoking because it affects others, not only you." -Saying that smoking is harmful to others and telling the client that she must quit forces a sense of guilt on the client. The statement may be seen as "preaching," without focusing on assisting the client to attain optimal health.

Direct questions

-ask for specific information -does not encourage client to ramble -useful for gathering biographic information

Preparation should include the

Self, look presentable and be internally ready/what questions you're going to ask Environment, make sure patient is comfortable otherwise they won't open up/if tv on turn it down or off

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation -The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will be well aware of the dangers of smoking

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation -The client will know that the nurse understands that it is hard to quit smoking if the nurse suggests methods available to help kick the smoking habit. The nurse should keep a neutral and friendly expression, and avoid any display of surprise or shock at the situation. A neutral, friendly expression will help the client to open up and explain to the nurse his efforts at breaking free from the habit. The nurse need not tell the client that excessive smoking could cause cancer, as the client will be well aware of the dangers of smoking.

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to

allow the client to verbalize his or her feelings. -When interacting with an angry client approach this client in a calm, reassuring, in-control manner. Allow him to ventilate feelings.

Describe the COLDSPA

-character, describe the sign or symptom -onset, where did it begin -location, where is it -duration, how long does it last -severity, how bad is it -pattern, what makes it better or worse -associated factors/how it affects the patient, what other symptoms occur with it, how does it affect you

Problem seeking involves

-identifying client's potential problem -subsequent data collection focuses on these problems

What are some therapeutic techniques to be used during the interview

-problem seeking -problem solving

When interacting with a manipulative client

-provide structure and set limits -differentiate between manipulation and a reasonable request -obtain an objective opinion from other nursing colleagues *do not get sucked into the story line, this takes a lot of experience to get used to

Basic communication strategies should include

-appearance/demeanor/facial expression/attitude/silence (allows for reflection, processing)/attentive listening (eye contact, facing the)/conveying acceptance

The three type os percussion are

-direct, 2 fingertips -blunt, hand flat pound hit back hand with fist (kidneys) -indirect, use one finger and strike

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance -The client's inability to sleep is being caused by anxiety which would be addressed within the coping-stress-tolerance category of the health pattern review. The client's anxiety is causing an issue within the category of sleep-rest.

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?

"Do you perform any sustained or continually repetitive motions with that arm?" -Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data. Be careful not to lead the client to answers that are not true. The question, "Do you perform any sustained or continually repetitive motions with that arm?" is open enough to not lead the client to an expected answer but narrow enough for the nurse to help elicit more information from the client about probable causes of his pain. Recommending that the client change his posture while working at the computer is premature, as the nurse has not confirmed that the computer work is the culprit. Likewise, "You work at a computer a lot, don't you?" is a leading question, as it encourages the client to answer in the affirmative. The question, "When did the pain start?" is a close-ended question; it will elicit more information from the client but is not an example of inferring.

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

"What diseases did you have as a child?" -Information covered in the personal health history section includes questions about birth, growth, development, childhood diseases, immunizations, allergies, medication use, previous health problems, hospitalizations, surgeries, pregnancies, births, previous accidents, injuries, pain experiences, and emotional or psychiatric problems.

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?" -Examples of questions related to associated factors include the following: "What other symptoms occur with it? How does it affect you? What do you think caused it to start? Do you have any other problems that seem related to it? How does it affect your life and daily activities?" The question, "How bad was the tingling and numbness?" relates to severity. The question, "How long did the spell last?" relates to duration. The question, "Where did the numbness and tingling occur?" relates to location.

When inspecting

-look and observe before touching -good lighting -completely expose part being examined

Collection of objective data includes

-physical characteristics, posture/amount of hair/bruises -body functions, how things are working -appearance, what clothing looks like -behavior, quiet/anxious/sleepy -measurements, length of arms/legs/vitals/bowel sounds -results of laboratory testing

What are the steps for preparing a health assessment?

-review client's record -review clients status with other health care members -educate about client's diagnosis and tests performed

Interacting with a seductive client

-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

Positions

-sitting -supine, lying on back, abdominal muscles relaxed -dorsal recumbent, lying back on table with knees bent, legs separated, feet flat -sims' (left lateral), on side, lower arm placed behind body, lower leg slightly flexed, upper leg flexed at sharper angle and pulled forward, rectal/vaginal -standing, posture/gait/balance -knee-chest, colonoscopy looking one (face down ass up), rectum -lithotomy, one where getting Pap smear, female genitalia -prone, lying on stomach

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

Make sure that dress and appearance are professional, Do not use facial expressions such as rolling the eyes or looking bored or disgusted, Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally -The physical appearance of the nurse sends a message to the client. Thus, it is important for nurses to ensure that their dress and appearance are professional. Facial expressions should be relaxed, caring, and interested. Facial expressions common in social situations (e.g., rolling the eyes, looking bored or disgusted) reduce trust. The nurse uses gestures intentionally to illustrate points, especially for clients who cannot communicate verbally. The nurse may point with a finger or gesture an action, such as pretending to drink or pointing to the bathroom. Gestures are purposeful rather than distracting from the communication

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?

The client -Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources. In some cases, the client's immediate family or caregiver may be a more accurate source of information than the client. An example would be an older adult client's wife who has kept the client's medical records for years or the legal guardian of a mentally compromised client.

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

health maintenance -One area within health maintenance is completion of vaccinations. If the client cannot recall when the last immunizations were received, this would impact health maintenance.

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question?

"I just wanted to see what kind of social support you might have to help care for you during your illness." -Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. In this way, you can assess problems and potential support from the client's family of origin

Non-therapeutic communication techniques include

-asking personal questions -giving personal opinions -changing the subject -automatic responses -false reassurance -biased or leading questions -rushing through interview -reading the questions -sympathy/asking for explanations/approval/disapproval/defensive responses/passive or aggressive response/arguing

When discussing sensitive issues

-be aware of your own thoughts and feeling regarding dying/spirituality/sexuality -ask simple questions in a nonjudgmental manner -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

Collection of subjective data includes

-biographical information, name/phone/SS/religion/education/address -history of present health concern; physical symptoms related to each body part or system -past health history - family history, genetic link? -health and lifestyle practices, what does sleep mean to them/how they cope with stress/smoke/drink

Assessment skills include

-cognitive, need to be able to understand, not just memorize -problem-solving skills, know who to ask if you do not know the answer/collaborate -psychomotor skills, hands on/ability to perform the care -interpersonal skills, communication/get them to trust you/show genuine in your caring -ethical skills, know what's right or wrong/the limits of your license

Lifestyle and health practices

-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/belief systems -education and work -stress levels and coping styles -environment

Special considerations when communicating with clients

-emotional state of the client, anxiety/angry/depressed/manipulative/seductive/sensitive issues

When interacting with a depressed client

-express interest in and understanding of the client and respond in a neutral manner -take care not to communicate in an upbeat/encouraging manner

Open-ended questions

-goal is to elicit more in-depth response -allows patient to tell their story -explain/how/give/tell/describe/where/when/who

What are the dimensions of nursing assessments?

-physiological, that functional piece of the body -psychological, if mother in labor is worried about something it can slow down the process -psychosocial, environment/family/support networks -cultural, don't need to be culturally competent/must be open/how can you be present for them -developmental, different interventions/actions/are they meeting those milestones -spiritual, might refuse medical treatment and choose to pray instead/what, how they believe, you're allowed to ask their spirituality otherwise you don't have a complete picture

The summary/closing/termination phase of the interview consists of

-summarizing the information gathered -problems and goals validated with client -helpful to let client know when interview will end *making sure you and patient are on the same page

Step of physical exam

-wash hands prior to exam -explain procedure, followed by physical assessment -respect client and desires -leave when they change clothes -begin with less intrusive procedure -consider patient positioning -EXPLAIN

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?

Active listening -Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion.

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications. -Because many people use vitamins or a variety of herbal supplements, it is important to ask which ones and how often. These supplements and prescription medications may interact (e.g., garlic decreases coagulation and interacts with warfarin [Coumadin])

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

To clarify -Another way to clarify is to ask, "What happens when you get low blood sugar?" Such questions prompt clients to identify other symptoms or give more information so that you can better understand the situation

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram -A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance -Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment.

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter -The client's memory was cloudy but the adult daughter was able to provide the exact date based upon a life event that can be validated. This interaction does not indicate that the adult daughter is controlling the interview. The client was unable to recall the exact date of the surgery but with the daughter's help, the date was provided. The exact information about the surgical date and the person who provided the information should be documented. The client may have been confused, but that is not what needs to be documented.

Percussion allows to

-elicit pain -determine location/size/shape -density -detects abnormal masses -elicit reflexes *sending sound through the body

Nonverbal communication to avoid includes

-excessive or insufficient eye contact -distraction and distance -standing