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Assessment Data Characteristics:

1. Complete

2. Factual

3. Accurate

4. Relevant

Consider:

1. Time

2. Needs of patient

3. Developmental stage

4. Physical surroundings

5. Past & present coping patterns

Primary source of information: PATIENT

Secondary: Family members, client record, medical record,

lab records.

Data Collection Methods:

1. Observation- using senses

2. Interviewing

3. Physical Assessment Methods of Physical Assessment:

a. Inspection- sense of sight, ensure good

lighting, perform at every encounterwith your client.

b. Percussion- assess location, size, density

Types:

-Direct sinus tenderness

-Indirect- lung percussion

-Blunt- organ tenderness

c. Palpation-temperature, moisture, texture,

size/location, vibration, position, pain.

Techniques: -Light, deep, Bimanual

d. Auscultation-use of stethoscope

**Techniques of Physical Assessment:1. General survey

2. Heat to toe or systems approach

3. Minimize exposure

4. Assess unaffected areas first

5. Assess external before internal parts

INTERVIEWING= a planned communication with a

purpose.

=Types of questions & rapport are important.

4 Phases of a Nursing Interview:

1. Preparatory phase

2. Introduction3. Working Phase

4. Termination Phase

1. Preparatory Phase

A nurse collects background info from previous

charts.

Ensure environment is conducive.

Arrange seating (3-4 ft apart, interviewer at

45degree to patient)

Allow adequate time.

2. Introduction Phase

Nurse introduces self

Identifies purpose of interview

Ensure confidentiality of info

Provide for patient needs before starting.

3. Working Phase

Nurse gathers info forsubjective data

Excellent communication skills are needed

=Active listening

=Eye contact

=Open-ended questions

4. Termination Phase Inform patient when nearing end of interview

Ensure that patient knows what will happen with

info.

Offer patient chance to add anything

Principles of Interview/ Communication Skills:

1. Establish rapport

2. Respect patient privacy

3. Recognize nonverbal clues (facial expression)

4. Move to the patients field of vision

5. Ask open-ended questions, one thing at a time6. Leave the medical terminology alone

7. Listen

8. Be honest, respectful, patience

9. Be sensitive to cultural nuances

10. Pay attention to accuracy & details

11. Speak clearly & audibly

12. Always ask for clarification

During interview, DO NOT:

1. Offer comments2. Interrupt a response

3. Superimpose your own point of view

4. Allow your tone of voice to betray your thoughts

5. Jump into conclusion

6. Speak too fast or too slow

7. Use technical terms/medical terms

Types of Questions:

1. Open-ended questions- verbalize freely

2. Closed questions- elicit specific info

3. Reflecting questions- elaborate on thoughts/feelings

4. Direct questions- validate/clarify info

Problems r/t Data Collection

1. Inappropriate organization of database

2. Omission of pertinent data3. Inclusion or irrelevant, erroneous or misinterpreted data

4. Failure to establish rapport & partnership

5. Recording an interpretation of data rather then observed

behavior

When to Verify Data:

1. When there is discrepancy b/t what the person is saying &

what the nurse is observing

2. When data lack objectivity

HEALTH HISTORY- collection of SUBJECTIVE data

-Obtain thru interview.-Identify strength, actual or potential problems,

support system, teaching needs.

-Use of effective communication skills.

Complete Health History:

1. Biographical Data (name, age, birthplace, gender, marital

status, occupation)

2. Reason for Seeking Care (symptoms, duration)3. History of Present Illness

= arranges symptoms in chronological order from the

time of onset to present time.

=Includes analysis of symptomsP Provokes What makes it worse/better?

Q Quality What does pain feel like?R Region Where?

S Severity Scale of 1-10T Time When, how often?

4. Past Health5. Accidents & Injuries

6. Hospitalizations & Operations

7. Family History

8. Review of Systems

9. Functional Assessment (Activities of Daily Living)

10. Perception of Health

Therapeutic Comm. Tech Non-Therapeutic

1. Using silence 1. Giving reassurance

2. Accepting 2. Rejecting

3. Giving recognition 3. Approving/Disapprovin

4. Giving broad openings 4. Giving advice5. Restating 5. Probing6. Focusing 6. Defending

7. Exploring 7. Belittling feelings

8. Voicing doubt 8. Aggreeing/Disagreeing

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9. Present reality 9. Requesting explanation