COLLECTING SUBJECTIVE DATA By: JOHER B. MENDEZ, JR., RN, MD 1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information 2. Gathering information on the client’s developmental, psychological, physiologic, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse–client collaboration. 2 FOCI OF INTERVIEWING PREINTRODUCTORY INTRODUCTORY PHASE PHASE WORKING PHASE SUMMARY AND CLOSING PHASE PHASES OF THE INTERVIEW NONVERBAL VERBAL COMMUNICATION COMMUNICATION COMMUNICATION DURING THE INTERVIEW Appearance Demeanor Facial Expression Attitude Silence Listening NONVERBAL COMMUNICATION Excessive Contact or Insufficient Eye Distraction Distance Standing NONVERBAL COMMUNICATION TO AVOID Open-ended questions Closed-ended Laundry questions list Rephrasing Well-placed phrases Inferring Providing information VERBAL COMMUNICATION Biased or leading questions Rushing through the interview Reading the questions VERBAL COMMUNICATION TO AVOID Gerontologic Variations in Communication Cultural Variations in Communication Emotional Variations in Communication SPECIAL CONSIDERATIONS DURING INTERVIEW First assess hearing acuity. If you detect hearing loss, speak slowly, face the client at all times during the interview and position yourself so that you are speaking on the side of the client that has the ear with better equity. Establish and maintain trust, privacy and partnership with the older client. Speak clearly. Use straightforward language. Ask questions in simple terms. GERONTOLOGIC VARIATIONS IN COMMUNICATION Avoid medical jargon and modern slang. Do not talk down to the client. Show respect. GERONTOLOGIC VARIATIONS IN COMMUNICATION Reluctance to reveal personal information to strangers Variation in willingness to openly express emotional distress or pain Variation in ability to listen Variation in meaning conveyed by language Variation in use and and meaning of nonverbal communication CULTURAL VARIATIONS IN COMMUNICATION Variation in disease/illness perception Variation in past, present or future time orientation Variation in the family’s role in the decision-making process CULTURAL VARIATIONS IN COMMUNICATION Help the interpreter prepare and understand what needs to be done ahead of time. Remember, the interpreter is the “communication bridge” and not the “content expert.” Be patient. The interpreter’s timing may not match that of others involved. Speak slowly and clearly. Pause every few sentences so the interpreter can translate your information. TIPS FOR WORKING WITH INTERPRETERS Give the family and the interpreter a break. Express the information in two or three different ways if needed. Use an interpreter to help ensure that the family can read and understand translated written materials. Avoid side conversations during sessions. Remember, just because someone speaks another language doesn’t mean that he or she will make a good interpreter. Do not use children as interpreters. TIPS FOR WORKING WITH INTERPRETERS INTERACTING WITH CLIENTS WITH VARIOUS EMOTIONAL STATES: 1. An anxious client 2. An angry client 3. A depressed client 4. A manipulative client 5. A seductive client 6. When discussing sensitive issues (e.g. sexuality, dying, spirituality EMOTIONAL VARIATIONS IN COMMUNICATION Provide the client with simple, organized information in a structured format. Explain who you are, along with your role and purpose. Ask simple, concise questions. Avoid becoming anxious like the client. Do not hurry, and decrease any external stimuli. INTERACTING WITH AN ANXIOUS CLIENT Approach client in a calm, reassuring, in-control manner. Allow him to ventilate feelings. However, if the client is out of control, do not argue with or touch the client. Obtain help from other health care professionals as needed. Avoid arguing and facilitate personal space so that the client does not feel threatened or cornered. INTERACTING WITH AN ANGRY CLIENT Express interest in and understanding of the client and respond in a neutral manner. Do not try to communicate in an upbeat, encouraging manner. This will not help the depressed client. INTERACTING WITH A DEPRESSED CLIENT Provide structure and set limits. Differentiate between manipulation and a reasonable request. If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues. INTERACTING WITH A MANIPULATIVE CLIENT Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors. Encourage client to use more appropriate methods of coping in relating to others. INTERACTING WITH A SEDUCTIVE CLIENT First, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client’s health and may need to be discussed with someone. Ask simple questions in a nonjudgmental manner. Allow time for ventilation of client’s feelings as needed. If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed. WHEN DISCUSSING SENSITIVE ISSUES Biographic data Reasons for seeking health care History of present health concern Personal health history Family health history Review of body systems for current health problems Lifestyle and health practices profile developmental level COMPLETE HEALTH HISTORY Information that identifies the client such as name, address, phone number, gender and who provided the information --- the client or significant others client’s birth date, Social Security number, medical record number, or similar identifying data date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read client’s educational level, occupation, and working status who lives with the client and identifying significant others BIOGRAPHIC DATA “What is your major health problem or concerns at this time?” “How do you feel about having to seek health care?” REASON (S) FOR SEEKING HEALTH CARE Encourage the client to explain the health problem or symptom in as much detail as possible by focusing on the onset, progression, and duration of the problem; signs and symptoms and related problems; and what the client perceives as causing the problem. Ask the client to evaluate what makes the problem worse, what makes it better, which treatments have been tried, what effect the problem has had on daily life or lifestyle, what expectations are held regarding recovery, and what is the client’s ability to provide self-care. A memory helper—known as a mnemonic— can help the nurse to complete the assessment of the sign, symptom, or health concern. (e.g. PQRST, COLDSPAR, COLDSTER, LOCSTAAM, COLDSPA) HISTORY OF PRESENT HEALTH CONCERN Ask the client about any childhood illnesses and immunizations to date. Adult illnesses (physical, emotional, and mental) are then explored. Ask the client to recall past surgeries or accidents. Ask the client to describe any prolonged episodes of pain or pain patterns he or she has experienced. Inquire about any allergies (food, medicine, pollens, other) and use of prescription and over-the-counter (OTC) medications. PERSONAL HEALTH HISTORY Include as many genetic relatives as the client can recall. Include maternal and paternal grandparents, aunts and uncles on both sides, parents, siblings, and the client’s children. Include the client’s spouse but indicate that there is no genetic link. Draw a genogram to organize and illustrate the client’s family history. Prepare a brief summary of the kinds of health problems present in thefamily. FAMILY HEALTH HISTORY Skin, hair, and nails: Skin color, temperature, condition, excessive sweating, rashes, lesions, balding, dandruff, condition of nails Head and neck: Headache, swelling, stiffness of neck, difficulty swallowing, sore throat, enlarged lymph nodes Eyes: Vision, eye infections, redness, excessive tearing, halos around lights, blurring, loss of side vision, moving black spots/specks in visual fields, flashing lights, double vision, and eye pain Ears: Hearing, ringing or buzzing, earaches, drainage from ears, dizziness, exposure to loud noises Mouth, throat, nose, and sinuses: Condition of teeth and gums; sore throats; mouth lesions; hoarseness; rhinorrhea; nasal obstruction; frequent colds; sneezing or itching of eyes, ears, nose, or throat; nose bleeds; snoring REVIEW OF SYSTEMS (ROS) FOR CURRENT HEALTH PROBLEMS Thorax and lungs: Difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, cough or sputum, hemoptysis, respiratory infections Breasts and regional lymphatics: Lumps or discharge from nipples, dimpling or changes in breast size, swollen or tender lymph nodes in axilla Heart and neck vessels: Last blood pressure, ECG tracing or findings, chest pain or pressure, palpitations, edema Peripheral vascular: Swelling, or edema, of legs and feet; pain; cramping; sores on legs; color or texture changes on the legs or feet Abdomen: Indigestion, difficulty swallowing, nausea, vomiting, abdominal pain, gas, jaundice, hernias REVIEW OF SYSTEMS (ROS) FOR CURRENT HEALTH PROBLEMS Male genitalia: Excessive or painful urination, frequency or difficulty starting and maintaining urinary stream, leaking of urine, blood noted in urine, sexual problems, perineal lesions, penile drainage, pain or swelling in scrotum, difficulty achieving an erection and/or difficulty ejaculating, exposure to sexually transmitted infections (STIs) Female genitalia: Sexual problems; STIs; voiding problems (e.g., dribbling, incontinence); reproductive data such as age at menarche, menstruation (length and regularity of cycle), pregnancies, and type of or problems with delivery, abortions, pelvic pain, birth control, menopause (date or year of last menstrual period), and use of hormone replacement therapy (HRT) REVIEW OF SYSTEMS (ROS) FOR CURRENT HEALTH PROBLEMS Anus, rectum, and prostate: Bowel habits, pain with defecation, hemorrhoids, blood in stool, constipation, diarrhea Musculoskeletal: Swelling, redness, pain, stiffness of joints, ability to perform ADLs, muscle strength Neurologic: General mood, behavior, depression, anger, concussions, headaches, loss of strength or sensation, coordination, difficulty speaking, memory problems, strange thoughts and/or actions, difficulty learning REVIEW OF SYSTEMS (ROS) FOR CURRENT HEALTH PROBLEMS Description of typical day Nutrition and weight management Activity level and exercise Sleep and rest Substance use Self-concept and self-care responsibilities Social activities Relationships LIFESTYLE AND HEALTH PRACTICES PROFILE Values and belief system Education Stress and work levels and coping styles Environment LIFESTYLE AND HEALTH PRACTICES PROFILE “Please tell me what an average or typical day is for you. Start with awakening in the morning and continue until bedtime.” DESCRIPTION OF TYPICAL DAY Ask the client to recall what consists of an average 24-hour intake with emphasis on what foods are eaten and in what amounts. Ask about snacks, fluid intake, and other substances consumed. Ask who buys and prepares the food as well as when and where meals are eaten. Consider reviewing the food pyramid with the client and explaining what a serving size is. Ask about the client’s bowel and bladder habits at this time. NUTRITION AND WEIGHT MANAGEMENT Sample Questions “What do you usually eat during a typical day? Please tell me the kinds of foods you prefer, how often you eat throughout the day, and how much you eat.” “Do you eat out at restaurants frequently?” “Do you eat only when hungry? Do you eat because of boredom, habit, anxiety, depression?” “Who buys and prepares the food you eat?” “Where do you eat your meals?” “How much and what types of fluids do you drink?” NUTRITION AND WEIGHT MANAGEMENT Assess how active the client is during an average week either at work or at home. Inquire about regular exercise. Make it a point to distinguish between activity done when working, which may be stressful and fatiguing, and exercise, which is designed to reduce stress and strengthen the individual. Explain to the client that regular exercise reduces the risk of heart disease, strengthens heart and lungs, reduces stress, and manages weight. ACTIVITY LEVEL AND EXERCISE Sample Questions “What is your daily pattern of activity?” “Do you follow a regular exercise plan? What types of exercise do you do?” “Are there any reasons why you cannot follow a moderately strenuous exercise program?” “What do you do for leisure and recreation?” “Do your leisure and recreational activities include exercise?” ACTIVITY LEVEL AND EXERCISE Inquire whether the client feels he is getting enough sleep and rest. Questions should focus on specific sleep patterns such as how many hours a night the person sleeps, interruptions, whether the client feels rested, problems sleeping (e.g., insomnia), rituals the client uses to promote sleep, and concerns the client may have regarding sleep habits. SLEEP AND REST Sample Questions “Tell me about your sleeping patterns.” “Do you have trouble falling asleep or staying asleep?” “How much sleep do you get each night?” “Do you feel rested when you awaken?” “Do you nap during the day? How often and for how long?” “What do you do to help you fall asleep?” SLEEP AND REST Sample Questions “How much beer, wine or other alcohol do you drink on average?” “Do you drink coffee or other beverages containing caffeine (e.g., cola)? If so, how much and how often?” “Do you now or have you ever smoked cigarettes or used any other form of nicotine? How long have you been smoking/did you smoke? How many packs per week? Tell me about any efforts to quit.” “Have you ever taken any medication not prescribed by your health care provider? If so, when, what type, how much, and why?” “Have you ever used, or do you now use, recreational drugs? Describe any usage.” “Do you take vitamins or herbal supplements? If so, what?” SUBSTANCE USE Sexual Basic responsibility hygiene practices Regularity of health care checkups (i.e., dental, visual, medical) Breast/testicular self-examination Accident prevention and hazard protection (e.g., seat belts, smoke alarms, and sunscreen). SELF-CONCEPT AND SELF-CARE RESPONSIBILITIES Sample Questions “What do you see as your talents or special abilities?” “How do you feel about yourself? About your appearance?” “Can you tell me what activities you do to keep yourself safe, healthy, or to prevent disease?” “Do you practice safe sex?” “How do you keep your home safe?” “Do you drive safely?” “How often do you have medical checkups or screenings?” “How often do you see the dentist or have your eyes (vision) examined?” SELF-CONCEPT AND SELF-CARE RESPONSIBILITIES Sample Questions “What do you do for fun and relaxation?” “With whom do you socialize most frequently?” “Are you involved in any community activities?” “How do you feel about your community?” “Do you think that you have enough time to socialize?” “What do you see as your contribution to society?” SOCIAL ACTIVITIES Ask clients to describe the composition of the family into which they were born and about past and current relationships with these family members. If the client does not have any family by blood or marriage, then information should be gathered about any significant others (including pets) that may constitute the client’s “family.” RELATIONSHIPS Sample Questions “Who is/are the most important person/s in your life? Describe your relationship with that person.” “What was it like growing up in your family?” “What is your relationship like with your spouse?” “What is your relationship like with your children?” “Describe any relationships you have with significant others.” “Do you get along with your in-laws?” “Are you close to your extended family?” “Do you have any pets?” “What is your role in your family? Is it an important role?” “Are you satisfied with your current sexual relationships? Have there been any recent changes?” RELATIONSHIPS Assess the client values. Discuss the clients’ philosophical, religious, and spiritual beliefs. VALUES AND BELIEF SYSTEM Sample Questions “What is most important to you in life?” “What do you hope to accomplish in your life?” “Do you have a religious affiliation? Is this important to you?” “Is a relationship with God (or another higher power) an important part of your life? “What gives you strength and hope?” VALUES AND BELIEF SYSTEM Questions should bring out data about the kind and amount of education the client has, whether the client enjoyed school, whether he perceives his education as satisfactory or whether there were problems, and what plans the client may have for further education, either formal or informal. Similar questions should be asked about work history. EDUCATION AND WORK Sample Questions “Tell me about your experiences in school or about your education.” “Are you satisfied with the level of education you have? Do you have future educational plans?” “What can you tell me about your work? What are your responsibilities at work?” “Do you enjoy your work?” “How do you feel about your coworkers?” “What kind of stress do you have that is workrelated? Any major problems?” “Who is the main provider of financial support in your family?” “Does your current income meet your needs?” EDUCATION AND WORK Ask questions that address what events cause stress for the client and how they usually respond. Find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive. STRESS LEVELS AND COPING STYLES Sample Questions “What types of things make you angry? “How would you describe your stress level?” “How do you manage anger or stress?” “What do you see as the greatest stressors in your life?” “Where do you usually turn for help in a time of crisis?” STRESS LEVELS AND COPING STYLES Ask questions regarding the client’s environment to assess health hazards unique to the client’s living situation and lifestyle. Look for physical, chemical, or psychological situations that may put the client at risk. ENVIRONMENT Sample Questions “What risks are you aware of in your environment such as in your home, neighborhood, on the job, or any other activities in which you participate?” “What types of precautions do you take, if any, when playing contact sports, using harsh chemicals or paint, or operating machinery?” “Do you believe you are ever in danger of becoming a victim of violence? Explain.” ENVIRONMENT
