Collecting Subjective Data: The Interview and Health History

Subjective Data

Collecting ___ is an integral part of interviewing the client to obtain a nursing health history.

Subjective Data

Consist of: Sensation or symptoms, Feelings, Perceptions, Desires, Preferences, Beliefs, Ideas, Values, Personal Information.

Nursing Interview

Is a communication process that has two focuses.

Interviewing 1.

Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information.

Interviewing 2.

Gathering information on the client's developmental, psychological, physiological, sociocultural, and spiritual status to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse-client collaboration.

Phases of Interview: Pre-introductory Phase

The nurse reviews medical record before meeting with the client.

Phases of Interview: Introductory Phase

After introducing yourself to the client, 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 that confidential information will remain confidential.

Phases of Interview: Working Phase

The nurse elicits the clients comments about major biographical data, reasons for seeking care, history of present health concern, past health history, family history; review of body system (ROS) for current health problems, lifestyle and health practices, and developmental level.

Pre-introductory Phase

Is a crucial, often overlooked part of the interview in health assessment.

Pre-introductory Phase

This phase sets the stage for a successful interaction and helps establish a foundation for trust and rapport.

Pre-introductory Phase: Preparation

This phase starts even before meeting the patient.

Pre-introductory Phase: Preparation

Reviewing the patient's chart: Familiarizing yourself with their medical history, previous encounters, and any relevant information.

Pre-introductory Phase: Preparation

Gathering supplies: Ensuring you have the necessary equipment, forms, and resources for the interview

Pre-introductory Phase: Preparation

Setting the stage: Ensuring the interview room is private, comfortable, and free of distractions.

Pre-introductory Phase: First Impressions

The moment you encounter the patient, even before the formal introduction, your demeanor (first impression through physical appearance) and nonverbal communication (facial expressions) matter.

Pre-introductory Phase: First Impressions

Smile and greet: A warm, genuine greeting can instantly put the patient at ease

Pre-introductory Phase: First Impressions

Eye contact: Making eye contact shows respect and interest in the patient

Pre-introductory Phase: First Impressions

Body language: Maintain an open posture, avoiding crossed arms or other gestures that could be perceived as closed off

Pre-introductory Phase: First Impressions

Professional attire: Maintain a professional appearance to convey competence and respect.

Pre-introductory Phase: Establishing Privacy and Confidentiality

Even before starting the interview; ensure the patient feels comfortable and secure.

Pre-introductory Phase: Establishing Privacy and Confidentiality

Confirm privacy: Close the door, pull the curtains, or take any steps to ensure the conversation is private

Pre-introductory Phase: Establishing Privacy and Confidentiality

Explain confidentiality: Reassure the patient that their information will be kept confidential.

Pre-introductory Phase: Setting the Tone

This phase is crucial for creating a positive and productive environment.

Pre-introductory Phase: Setting the Tone

Start with a relaxed conversation: Engage in brief, non-medical conversation to break the ice, such as asking about their day or how they got to the clinic

Pre-introductory Phase: Setting the Tone

Demonstrate empathy and respect: Show genuine interest in the patient as a person, not a medical case.

Benefits of a Strong Pre-Introductory Phase

Improved rapport: A positive initial interaction fosters trust and makes the patient more likely to open up.

Benefits of a Strong Pre-Introductory Phase

Reduced anxiety: A calm and reassuring environment can help alleviate the patient's stress and anxiety.

Benefits of a Strong Pre-Introductory Phase

More accurate information: When the patient feels comfortable and respected, they are more likely to provide accurate and complete information.

Introductory Phase

The introductory phase of the interview in health assessment is crucial for establishing a positive and productive foundation for the interaction.

Introductory Phase

It sets the tone for the entire encounter and helps build trust and rapport between the healthcare professional and the patient.

Introductory Phase: Introducing Yourself and Your Role Clear identification

Start by stating your name and your professional title (eg, "Hello, I'm Dr. Smith, and I'm a family physician").

Introductory Phase: Introducing Yourself and Your Role Explain your role

Briefly explain why you're there and what you'll be doing during the interview. For example, "I'll be asking you some questions about your health history and current concerns."

Introductory Phase: Introducing Yourself and Your Role Professional demeanor

Maintain a calm, confident, and reassuring demeanor throughout the introduction.

Introductory Phase: Explaining the Purpose of the Interview Clear and concise

Explain the purpose of the interview in simple, understandable terms. For example, "This interview is to gather information about your health so I can provide you with the best possible care."

Introductory Phase: Explaining the Purpose of the Interview Patient-centered approach

Emphasize that the interview is a collaborative process and that the patient's input is essential.

Introductory Phase: Explaining the Purpose of the Interview Time frame

If possible, provide a general idea of how long the interview will take.

Introductory Phase: Building Rapport and Trust Warm and welcoming

Use a friendly tone and a genuine smile to create a welcoming atmosphere.

Introductory Phase: Building Rapport and Trust Maintain: Active listening

Maintain eye contact and show that you are actively listening to the patient's responses.

Introductory Phase: Building Rapport and Trust Acknowledge: Empathy and understanding

Acknowledge the patient's feelings and concerns, even if you don't fully understand their perspective yet.

Introductory Phase: Building Rapport and Trust

Reassure: Non-judgmental approach: Reassure the patient that you will not judge them for any information they share.

Introductory Phase: Addressing Confidentiality

Importance of privacy: Emphasize that the information shared during the interview will be kept strictly confidential.

Introductory Phase: Addressing Confidentiality

Explain limitations: Briefly explain any limitations to confidentiality, such as legal requirements to report certain information (e.g., abuse).

Introductory Phase: Asking for Permission

Respectful approach: Before proceeding with the interview, ask the patient for their permission to begin. This demonstrates respect and empowers the patient in the process.

Introductory Phase: Example Introductory Script

"Hello, I'm Dr. Jones, and I'm a family nurse. I'll be conducting your health assessment today: This interview is to gather information about your health history and current concerns so that I can provide you with the best possible care. Please know that everything you share with me will be kept confidential, and I will be respectful of your feelings and concerns. Would it be okay if we begin now?"

Introductory Phase: Conclusion

Remember: The introductory phase is crucial for setting the stage for a successful and productive interview.

Introductory Phase: Conclusion

By taking the time to establish rapport, trust, and a clear understanding of the purpose of the interview, you can create an environment where the patient feels comfortable and empowered to share vital information.

Working Phase

The working phase of the health assessment interview is where the majority of information gathering takes place.

Working Phase

It's a dynamic process that requires skilled communication, active listening, and a tailored approach to each patient.

Working Phase: Gathering Information

Open-Ended Questions: Start with open-ended questions that encourage the patient to tell their story in their own words. For example, "Tell me about why you're here today," or "What brings you in for this visit?"

Working Phase: Gathering Information

Focused Questions: As the patient shares information, use focused questions to clarify details and gain further insight. For example, "Can you describe the pain you're experiencing?" or "When did you first notice these symptoms?"

Working Phase: Gathering Information

Review of Systems (ROS): Systematically ask about each body system (e.g., respiratory, cardiovascular, gastrointestinal) to identify any potential concerns the patient might not have mentioned.

Working Phase: Gathering Information

Health History: Gather information about the patient's past illnesses, surgeries, medications, allergies, family history, and social history.

Working Phase: Active Listening

Nonverbal cues: Pay attention to the patient's body language, facial expressions, and tone of voice. These cues can provide valuable insights into their emotions and experiences.

Working Phase: Active Listening

Summarizing and Clarifying: Periodically summarize what the patient has said and ask clarifying questions to ensure you understand their perspective.

Working Phase: Active Listening

Empathy and Validation: Acknowledge the patient's feelings and concerns, even if you don't fully agree with their perspective.

Working Phase: Tailoring the Approach

Patient-Centered: Focus on the patient's needs and concerns, rather than simply following a predetermined checklist.

Working Phase: Tailoring the Approach

Cultural Sensitivity: Be aware of cultural differences that may influence communication styles, beliefs about health, and willingness to share information.

Working Phase: Tailoring the Approach

Addressing Barriers: Identify and address any barriers to communication, such as language differences, hearing impairments, or cognitive limitations.

Working Phase: Building Trust and Rapport

Respectful Communication: Use a respectful and non-judgmental tone, avoiding medical jargon or terms that the patient might not understand.

Working Phase: Building Trust and Rapport

Active Engagement: Show genuine interest in the patient's story, ask follow-up questions, and maintain eye contact.

Working Phase: Building Trust and Rapport

Empathetic Responses: Acknowledge the patient's feelings and concerns with empathy, even if you cannot change the situation.

Working Phase: Documentation

Accurate and Comprehensive: Record the information gathered during the interview in a clear, concise, and accurate manner.

Working Phase: Documentation

Patient-Specific: Use language that is both objective and patient-specific, reflecting the individual's experiences and concerns.

Working Phase: Documentation

Confidentiality: Maintain the confidentiality of the patient's information, ensuring that it is not shared with unauthorized individuals.

Working Phase: Example Working Phase Script

"So, you mentioned that you've been experiencing chest pain. Can you tell me more about that? When did the pain start? Where is it located? What does the pain feel like? Is there anything that makes it better or worse?"

Working Phase: Remember

The working phase is a crucial part of the health assessment interview.

Working Phase: Remember

By actively listening, asking the right questions, and tailoring your approach to each patient, you can gather comprehensive information that will help you provide the best possible care.

Working Phase: Summary and Closing Phase

The nurse summarizes information obtained during the working phase and validates problems and goals with the client.

Communication During the Interview: Verbal Communication

Verbal communication is the cornerstone of the health assessment interview.

Communication During the Interview: Verbal Communication

It's how healthcare professionals gather information, build rapport, and convey crucial health information to patients.

Communication During the Interview: Verbal Communication

Excellent verbal communication is key. Aim to always speak with clarity, accuracy, and honesty.

Communication During the Interview: Verbal Communication

It's also important to know your audience and speak appropriately according to the person's age, culture, and level of health literacy.

Communication During the Interview: Verbal Communication

If you are feeling stressed out or frustrated, be aware of your tone of voice and don't let these emotions leak into your patient interaction.

Communication During the Interview: Verbal Communication

Encourage patients to communicate by asking open questions like, "Can you tell me a bit more about that?"

Communication During the Interview: Verbal Communication

Avoid condescending pet names like "honey" or "sweetie" and instead use the patient's first name or name of choice.

Communication During the Interview: Verbal Communication

Speak in clear, complete sentences and avoid technical jargon.

Communication During the Interview: Effective Communication Skills

Active Listening

Communication During the Interview: Effective Communication Skills

Written Communication

Communication During the Interview: Effective Communication Skills

Nonverbal Communication

Communication During the Interview: Effective Communication Skills

Presentation Skills

Communication During the Interview: Effective Communication Skills

Patient Education

Communication During the Interview: Effective Communication Skills

Compassion

Communication During the Interview: Effective Communication Skills

Cultural Awareness

Communication During the Interview: Effective Communication Skills

Personal Connections

Communication During the Interview: Effective Communication Skills

Trust

Verbal Communication: Active Listening

Focus on the Patient: Pay undivided attention to the patient's words, tone, and non-verbal cues. Avoid interrupting or letting your mind wander.

Verbal Communication: Active Listening

Summarize and Clarify: Periodically summarize what the patient has said to ensure you understand their message accurately. Ask clarifying questions when needed.

Verbal Communication: Active Listening

Empathetic Responses: Demonstrate understanding and empathy by acknowledging the patient's feelings and concerns. Use phrases like "It sounds like you're feeling frustrated" or "I can see how this situation would be difficult for you."

Verbal Communication: Clear and Concise Language

Avoid Medical Jargon: Use simple, everyday language that the patient can easily understand. Explain any medical terms you use.

Verbal Communication: Clear and Concise Language

Structure Your Questions: Ask questions that are clear and concise, avoiding double negatives or complex sentence structures.

Verbal Communication: Clear and Concise Language

Check for Understanding: After explaining something, ask the patient to repeat back what they've heard to ensure comprehension.

Verbal Communication: Asking Effective Questions

Open-Ended Questions: Encourage the patient to share their story in their own words by asking open-ended questions that can't be answered with a simple "yes" or "no." For example, "Tell me about your experience with this pain."

Verbal Communication: Asking Effective Questions

Focused Questions: Use focused questions to gather specific details about symptoms, medications, or past medical history. For example, "When did the pain start?" or "What medications are you currently taking?"

Verbal Communication: Asking Effective Questions

Reflective Questions: Reflect back the patient's feelings or concerns to show that you understand. For example, "It sounds like you're worried about the results of your test."

Verbal Communication: Non-Judgmental Tone

Respectful Language: Use respectful language, avoiding slang or informal terms.

Verbal Communication: Non-Judgmental Tone

Neutral Expressions: Maintain a neutral facial expression and tone of voice, even when discussing sensitive topics.

Verbal Communication: Non-Judgmental Tone

Avoid Interrupting: Allow the patient to finish their thoughts without interrupting.

Verbal Communication: Providing Information

Plain Language: Explain health information in a clear and straightforward manner. Avoid using complex medical terminology.

Verbal Communication: Providing Information

Check for Comprehension: After providing information, ask the patient if they have any questions or if they need further clarification.

Verbal Communication: Providing Information

Tailored Explanations: Adapt your explanations to the patient's level of understanding and literacy.