CHAPTER 2 COLLECTING OF SUBJECTIVE DATA

subjective data

information that only the client can describe

primary subjective data

the patient`s feeling as directly reported

secondary subjective data

subjective information provided by someone other than the patient (e.g family members, friend or caregivers)

primary objective data

direct observation/measurement

secondary objective data

data gathered from other healthcare providers (e.g lab results, medical records)

introductory phase, working phase, summary & closing phase

phases of the nursing interview

introductory phase

• also known as the orientation phase

• To establish trust and rapport with the patient.

• To explain the purpose of the interaction.

• To set the tone and boundaries of the relationship.

  • To gather initial information about the patient’s condition or concerns.

working phase

• also referred to as the intervention phase

• To address the patient’s health concerns and needs.

• To implement nursing interventions and strategies.

• To facilitate problem-solving and promote positive changes in the patient’s condition or behavior.

summary & closing phase

• also known as the termination phase

• To summarize and evaluate the care provided.

• To assess whether the goals and outcomes have been met.

• To provide closure and ensure continuity of care.

verbal communication, non verbal communication

2 essential types of communication in the client interview

appearance

dress professionally (uniform or lab coat)

demeanor

be professional

be calm, focused, and composed

avoid loudness, joking or appearing distracted

facial expression

keep expressions neutral yet warm

attitude

be nonjudgemental

avoid critical appearing superior

listening

your most important skill

silence is powerful

allows both client and nurse to reflect

encourages deeper, more thoughtful sharing

open-ended questions

encourage client to express feelings and perceptions

usually start with how or what

closed-ended questions

obtain specific or focus on details

usually start with when or did

laundry list

provide client with a list of descriptive words

helps narrow down symptoms or feelings

rephrasing

restate client`s statements to clarify and confirm

helps both nurse and client reflect on information

well-placed phrases

use short verbal encouragers like “um,yes,i see”

shows active listening

assurance ba

inferring

draw conclusion from client`s words and body language

helps elicit or verify additional information

use client`s own words to maintain clarity

providing information

answer client`s questions clearly during the interview

if unsure, promise to find the answer