Nurs 3320 - Subjective and Objective data

What are the Phases of the interview?

• Pre-introductory phase → Review medical record before meeting client.

• Introductory phase → Introduce self, explain purpose, build rapport, ensure privacy.

• Working phase → Collect health history, use questioning techniques.

• Summary/Closing phase → Summarize info, validate accuracy, discuss next steps.

What are the key elements of Non-verbal communication?

• Appearance → professional dress, hygiene.

• Demeanor → calm, respectful, professional.

• Facial expressions → attentive, friendly, culturally appropriate.

• Silence → allows client time to think/respond.

• Listening → active listening shows respect and interest.

What Non-verbal communication should you avoid?

• Excessive/awkward eye contact (staring).

• Distractions (looking at phone, watch).

• Distance that invades personal space.

• Negative facial expressions (frowning, disapproval).

• Rigid or closed posture (arms crossed, leaning away).

What are Verbal communication types (questioning)?

Open-ended questions or statements

• How?” or “What?” or “Tell me .....”.

Closed-ended questions: “When?”; “Did?”

• Keeps the interview on course, clarifying

Laundry list: (“Is pain sharp, dull, mild, stabbing?”)

Rephrasing: clarify information; allows reflection

What are verbal communications you need to avoid?

• Biased/leading questions → “You don’t smoke, do you?”

• Rushing client or talking too much.

• Using medical jargon client may not understand.

• Interrupting or finishing client’s sentences.

What are the components of a Complete health history?

• Biographical data

• Reasons for seeking care (chief complaint)

• History of present concern (symptom analysis: onset, duration, location, severity, etc.)

• Personal health history (illnesses, surgeries, allergies, medications, immunizations)

• Family history (genogram or family tree of health conditions)

• Review of systems (ROS) (head-to-toe symptom review)

• Lifestyle & health practices (nutrition, sleep, exercise, stress, substance use, culture, roles/relationships, environment, safety practices)

For a patient exam how do prepare the setting?

• Provide for comfort, warm temperature

• Private, quiet area free of interruption

• Firm examination table or bed, good lighting

• Bed- waist height to prevent stooping/bending (protect back)

What are the Four Assessment Techniques?

1. Inspection (look)

2. Palpation (feel)

3. Percussion (tap)

4. Auscultation (listen)

Abdomen order → Inspection → Auscultation → Percussion → Palpation
(to avoid altering bowel sounds).

What is Inspection?

First step the moment you meet the client.

• Use eyes, nose, sometimes ears.

• Look for: size, color, shape, symmetry, movement, position, odor.

• Compare side to side.

What is Palpation?

• Use touch to feel: texture, temperature, moisture, motion, consistency, tenderness.

• Light palpation → 1 cm depth (surface abnormalities, tenderness).

• Deep palpation → 2.5–5 cm (organs, masses).

Parts of hand used:

• Fingertips → texture, pulsations, small lumps.

• Ulnar surface/palm base → vibration.

• Dorsal side (back of hand) → temperature.

What is Percussion?

Tapping body to hear sound differences → helps assess underlying structures.

What is Auscultation?

Use stethoscope directly on skin (never over clothes).

• Assess heart, lung, bowel, vascular sounds.

• Bell → low-pitched sounds (murmurs, bruits).

• Diaphragm → high-pitched sounds (breath, normal heart, bowel).