Nursing Data Collection, Documentation, and Analysis

UNIT II Nursing Data Collection, Documentation, and Analysis 3 COLLECTING SUBJECTIVE DATA Collecting subjective data is an integral part of nursing Phases of the Interview health assessment. Subjective data consist of The nursing interview has three basic phases: introductory, • Sensations or symptoms working, and summary and closing phases. These phases • Feelings are briefly explained by describing the roles of the nurse • Perceptions and client during each one. • Desires • Preferences • Beliefs Introductory Phase • Ideas After introducing himself to the client, the nurse explains • Values the purpose of the interview, discusses the types of ques- • Personal information tions that will be asked, explains the reason for taking These types of data can be elicited and verified only by notes, and assures the client that confidential information the client. Subjective data provide clues to possible phys- will remain confidential. The nurse also makes sure that iologic, psychological, and sociologic problems. They the client is comfortable (physically and emotionally) and also provide the nurse with information that may reveal has privacy. It is also essential for the nurse to develop a client’s risk for a problem as well as areas of strengths trust and rapport at this point in the interview. This can for the client. begin by conveying a sense of priority and interest in The information is obtained through interviewing. the client. Developing rapport depends heavily on verbal Therefore, effective interviewing skills are vital to accurate and nonverbal communication on the part of the nurse. and thorough collection of subjective data. These types of communication are discussed later in the chapter. INTERVIEWING Working Phase Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills. The nursing During this phase, the nurse elicits the client’s comments interview is a communication process that has two focuses: about major biographic data, reasons for seeking care, history of present health concern, past health history, family 1. Establishing rapport and a trusting relationship history, review of body systems for current health prob- with the client to elicit accurate and meaningful lems, lifestyle and health practices, and developmental information and level. The nurse then listens, observes cues, and uses crit- 2. Gathering information on the client’s developmen- ical thinking skills to interpret and validate information tal, psychological, physiologic, sociocultural, and received from the client. The nurse and client collaborate spiritual statuses to identify deviations that can be to identify the client’s problems and goals. The facilitating treated with nursing and collaborative interventions approach may be free-flowing or more structured with or strengths that can be enhanced through nurse– specific questions, depending on the time available and client collaboration. the type of data needed. 29 30 UNIT II • NURSING DATA COLLECTION, DOCUMENTATION, AND ANALYSIS Summary and Closing Phase what you think about a client or what kind of day you are having, keep your expression neutral and friendly. If your During the summary and closing, the nurse summarizes face shows anger or anxiety, the client will sense it and information obtained during the working phase and vali- may think it is directed toward him or her. If you cannot dates problems and goals with the client (see Chapter 5). effectively hide your emotions, you may want to explain She also identifies and discusses possible plans to resolve that you are angry or upset about a personal situation. the problem (nursing diagnoses and collaborative prob- Admitting this to the client may also help in developing a lems) with the client (see Chapter 6). Finally, the nurse trusting relationship and genuine rapport. makes sure to ask if anything else concerns the client and Portraying a neutral expression does not mean that if there are any further questions. your face lacks expression. It means using the right expression at the right time. If the client looks upset, you should Communication During the Interview appear and be understanding and concerned. Conversely, smiling when the client is on the verge of tears will cause The client interview involves two types of communi- the client to believe that you do not care about his or her cation—nonverbal and verbal. Several special techniques problem. and certain general considerations will improve both types of communication and promote an effective and productive interview. ATTITUDE One of the most important nonverbal skills to develop as Nonverbal Communication a health care professional is a nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, Nonverbal communication is as important as verbal com- lifestyle, and health care practices. Do not act superior to munication. Your appearance, demeanor, posture, facial the client or appear shocked, disgusted, or surprised at expressions, and attitude strongly influence how the client what you are told. These attitudes will cause the client to perceives the questions you ask. Never overlook this type feel uncomfortable opening up to you and important data of communication or take it for granted. concerning his or her health status could be withheld. Being nonjudgmental involves not “preaching” to the client or imposing your own sense of ethics or morality on APPEARANCE him. Focus on health care and how you can best help the First take care to ensure that your appearance is profes- client to achieve the highest possible level of health. For sional. The client is expecting to see a health professional; example, if you are interviewing a client who smokes, therefore, you should look the part. Wear comfortable, avoid lecturing condescendingly about the dangers of neat clothes and a laboratory coat or a uniform. Be sure smoking. Also, avoid telling the client he or she is foolish your name tag, including credentials, is clearly visible. Your or portraying an attitude of disgust. This will only harm the hair should be neat and not in any extreme style; some nurse–client relationship and will do nothing to improve nurses like to wear long hair pulled back. Fingernails the client’s health. The client is, no doubt, already aware of should be short and neat; jewelry should be minimal. the dangers of smoking. Forcing guilt on him is unhelpful. Accept the client, be understanding of the habit, and work together to improve the client’s health. This does not mean DEMEANOR you should not encourage the client to quit; it means that Your demeanor should also be professional. When you how you approach the situation makes a difference. Let the enter a room to interview a client, display poise. Focus on client know you understand that it is hard to quit smoking, the client and the upcoming interview and assessment. Do support efforts to quit, and offer suggestions on the latest not enter the room laughing loudly, yelling to a coworker, methods available to help kick the smoking habit. or muttering under your breath. This appears unprofes- sional to the client and will have an effect on the entire SILENCE interview process. Greet the client calmly and focus your full attention on her. Do not be overwhelmingly friendly Another nonverbal technique to use during the interview or “touchy”; many clients are uncomfortable with this type process is silence. Periods of silence allow you and the of behavior. It is best to maintain a professional distance. client to reflect and organize thoughts, which facilitates more accurate reporting and data collection. FACIAL EXPRESSION LISTENING Facial expressions are often an overlooked aspect of communication. Because facial expression often shows what Listening is the most important skill to learn and develop you are truly thinking (regardless of what you are saying), fully in order to collect complete and valid data from your keep a close check on your facial expression. No matter client. To listen effectively, you need to maintain good CHAPTER 3 • COLLECTING SUBJECTIVE DATA 31 eye contact, smile or display an open, appropriate facial Verbal Communication expression, maintain an open body position (open arms and hands and lean forward). Avoid preconceived ideas or Effective verbal communication is essential to a client biases about your client. To listen effectively, you must interview. The goal of the interview process is to elicit as keep an open mind. Avoid crossing your arms, sitting back, much data about the client’s health status as possible. tilting your head away from the client, thinking about other Several types of questions and techniques to use during things, or looking blank or inattentive. Becoming an effec- the interview are discussed in the following sections. tive listener takes concentration and practice. In addition, several nonverbal affects or attitudes OPEN-ENDED QUESTIONS may hinder effective communication. They may promote discomfort or distrust. Display 3-1 describes communica- Open-ended questions are used to elicit the client’s feel- tion to avoid. ings and perceptions. They typically begin with the words DISPLAY 3-1 COMMUNICATION TO AVOID Nonverbal Communication to Avoid Excessive or Insufficient Eye Contact: Avoid extremes in eye contact. Some clients feel very uncomfortable with too much eye contact; others believe that you are hiding something from them if you do not look them in the eye. Therefore, it is best to use a moderate amount of eye contact. For example, establish eye contact when the client is speaking to you but look down at your notes from time to time. A client’s cultural background often determines how he feels about eye contact (see Cultural Variations in Communication for more information). Distraction and Distance: Avoid being occupied with something else while you are asking questions during the interview. This behavior makes the client believe that the interview may be unimportant to you. Avoid appearing mentally distant as well. The client will sense your distance and will be less likely to answer your questions thoroughly.

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