history and documentation

Patient Interviewing and Data Types

  • Two broad data sources in nursing assessments:
    • Primary data: the patient themselves.
    • Secondary data: everyone else around the patient (family members like daughter, mother, father, brother, sister, caregivers, etc.).
  • Data categories to capture:
    • Subjective data: what the patient reports (feelings, perceptions, symptoms, beliefs).
    • Objective data: what you observe or measure directly (the signs you can see, hear, touch, smell) based on accepted standards, not personal opinions.
  • Important reminder: objective data should be based on accepted standards and direct observation whenever possible; avoid making statements like "+it smells infected" without objective evidence.
  • The goal of interviewing is to gather information accurately and fairly, avoiding bias and stereotypes, and reflecting on how you approach each patient with awareness of differences (e.g., gender identity, cultural background, living situation).

Open-Ended Questions and Communication

  • Use open-ended questions to encourage patients to talk: e.g.,
    • "Tell me what brought you in today."
    • "What feelings are you experiencing about this condition?"
  • Begin encounters with a friendly introduction: e.g., "Hi, Amy. I’m Kim, your nurse today. I’m going to take your vital signs and do an assessment."
  • Open-ended questions help you gather richer data and reduce the risk of leading the patient.

Phases of the Nursing Interview (Working Phase and Beyond)

  • Working phase: collecting data and interpreting interview information; aim to avoid bias and reflect on your own preconceptions.
  • Orientation phase: establish rapport, explain what you will do, and set expectations.
  • Termination: summarize the data with the patient and confirm accuracy.
  • Reflective practice: consciously examine your own biases and assumptions in every situation (e.g., transgender patients, patients from other countries, nursing home residents, children).

Data Collection: Present Illness, Symptoms, and Data Quality

  • Present illness/presenting problem: gather information about what brought the patient in today, including symptoms and feelings.
  • Ensure information is accurate and factual; focus on presenting problems, symptoms, and their progression.
  • Align with the PQRST framework for symptom assessment (see next section).
  • Goal: collect accurate data to form a reliable clinical picture and fair treatment plan.

PQRST: Pain and Symptom Assessment (Upcoming Slide Reference)

  • PQRST components (common framework for medical history of symptoms):
    • P: Provoking factors or Palliation (what makes it better or worse)
    • Q: Quality (descriptive nature of the symptom, e.g., sharp, dull, throbbing)
    • R: Region or Radiation (where it is located and whether it radiates)
    • S: Severity (intensity; often on a scale, e.g., 0–10)
    • T: Timing (onset, duration, frequency; how long it lasts)
  • The patient’s orientation and communication can also help confirm data quality (e.g., if they are alert and oriented; speech clarity).

Mental Status and Neuro Checks During Interview

  • Assess alertness and orientation early as part of the interview: cognitive status can influence data reliability.
  • Observe speech clarity, language, and any signs of confusion or neglect.
  • Simple questions about orientation can reveal cognitive status and help guide further physical assessment.

System Review: Key Areas to Elicit Data From the Patient

  • Cardiovascular focus: primary concern is chest pain; also ask about dyspnea, orthopnea, palpitations, edema, and known risk factors.
  • Respiratory: assess for breathing difficulty, asthma, cough type (dry vs productive), and wheeze. Note whether patient can speak without stopping to take breaths; observe cough characteristics.
  • Neurologic: assess alertness/orientation, cognitive status, and any focal deficits; watch for changes that warrant further evaluation.
  • General approach: collect information for each body system in a way that makes sense to you and aligns with your assessment plan.

Pain Assessment: Describing and Documenting Pain

  • When patients describe pain, document both subjective reports and observable signs.
  • Example phrasing:
    • "The patient states pain is 10/10 and appears anxious; facial expression and body language show distress."
    • Distinguish between patient-reported pain and objective signs (e.g., tachycardia, labored breathing).
  • Consider how pain affects activity, sleep, appetite, and mood; note any prior pain experiences for comparison.

Physical Examination: Core Techniques and Sequence

  • The four fundamental techniques: inspection, palpation, percussion, auscultation.
  • Standard order: inspection → palpation → percussion → auscultation.
  • There is one notable exception: palpation is sometimes performed last when pain or guarding is expected, to avoid artifacting findings during auscultation.
  • Why the order matters: palpation can cause pain responses and muscle tension, which may alter findings if done too early.
  • Observational findings: mental state, mood, affect, posture, speech, level of comfort, ability to follow commands, and overall appearance.
  • Palpation involves feeling the patient’s body to assess texture, temperature, moisture, tenderness, and integrity.
  • Percussion helps identify organ size and density by producing characteristic sounds; dullness vs resonance can indicate underlying structures or masses (e.g., liver, spleen).
  • Auscultation requires using a stethoscope with its bell and diaphragm:
    • Diaphragm: best for high-pitched sounds (breath, heart sounds).
    • Bell: best for low-pitched sounds (vascular sounds, some heart murmurs).

Documentation Language, Abbreviations, and Note Formats

  • Be precise and avoid vague terms like "seems" or "patient hopes to"; write objective observations and concrete statements.
  • Common note structures:
    • DAR: Data → Action → Response (Data is what you observe, Action is what you did, Response is the outcome)
    • SOAP: Subjective → Objective → Assessment → Plan
    • PIE: Problem → Intervention → Evaluation
  • DAR example:
    • Data: Patient reports anxiety; HR = 110; RR = 22 with mild labored breathing.
    • Action: Administered PRN anxiolytic as ordered and provided calm environment.
    • Response: Patient reports reduced anxiety; HR decreased toward baseline over 15 minutes.
  • SOAP example: Subjective (patient states anxiety), Objective (HR 110, RR 22), Assessment (anxiety with elevated vitals), Plan (continue monitoring, administer PRN as ordered).
  • Abbreviations to avoid: ensure you comply with your program’s guidelines; reference lists for your institution may exist.
  • Emphasize data integrity and reproducibility; clear, legible documentation is essential for continuity of care and potential research applications.

Evidence-Based Practice in Nursing

  • Nursing practice should be informed by current research and best practices, not just tradition.
  • Flow from evidence to practice:
    • Identify a problem or area for improvement
    • Review current evidence and guidelines
    • Consider feasibility, ethics, and stakeholder input
    • Implement changes and monitor outcomes
    • Reflect on and adjust as needed
  • Spectrum vs single-dimension thinking:
    • Example: Wound management isn’t just about the wound itself (a single dimension) but the broader context: turning schedule, infection risk, moisture management, and patient activity; UTIs in catheterized patients illustrate a spectrum rather than a single cause.
  • Sources should be current (within a relevant number of years) and credible; apply findings to practice with appropriate adaptation.
  • Stakeholders in change processes include administrators, clinicians, patients, and families; effective communication with stakeholders is essential for successful implementation.
  • Ethical considerations: data collection and reporting must be ethical, transparent, and consent-based; avoid biased or exploitative research.
  • Real-world application: evidence-based practice helps improve patient flow, safety, and outcomes; even small changes can yield meaningful improvements.
  • The integration of clinical expertise, patient preferences, and research evidence is essential for high-quality