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COMPARING SUBJECTIVE AND OBJECTIVE DATA

SUBJECTIVE OBJECTIVE
DESCRIPTION: Data elicited and verified by
the client
Data directly or indirectly
observed through
measurement.
SOURCES: Client
Family and significant others
Client record
Other health care professionals
Observations and physical
assessment finding of the
nurse or other health care
professionals
Documentation of
assessments made in clients
record
Observations made by the
clients family or SO
METHODS USED TO OBTAIN DATA: Client interview Observation and physical
examination
SKILLS NEEDED TO OBTAIN DATA: Interview and therapeutic
communication skills
Caring ability and empathy
Listening skills
Inspection
Palpation
Percussion
Auscultation
EXAMPLE: I have a headache
It frightens me
I am not hungry
RR-16 cpm
BP-180/100 mmHg
Apical-80 and irregular
X-ray films revealed fractured
pelvis.

INTERVIEW is a planned communication or a conversation with a purpose, for example, to get or give
information, identify problems of mutual concerns, evaluates change, teach, provide support or
provide counseling or therapy.
2 FOCUSES:
1) Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful
information.
2) Gathering information on the clients developmental, psychological, physiological, 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 APPROACHES TO INTERVIEWING:
1. DIRECTIVE INTERVIEW highly structured and elicits specific information.
- The nurse establishes the purpose of the interview and controls the interview, at
least at the outset.
- Eg. Emergency situation
2. INDIRECTIVE INTERVIEW rapport-building interview.
- The nurse allows the client to control the purpose, subject matter, and pacing.
- RAPPORT = an understanding between 2 or more people.
PHASES OR STAGES OF AN INTERVIEW
1) OPENING OR INTRODUCTORY PHASE
Most important part of the interview because what is said and done at the time sets the tone for
the remainder of the interview.
The purposes of the opening are to establish rapport and orient the interviewee.
Establishing rapport is a process of creating goodwill and trust.
It can begin with a greeting or self-introduction accompanied by nonverbal gestures such as
smile.
After introducing 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.
The nurse also makes sure that the client is comfortable (physically and emotionally) and has
privacy.
2) BODY DEVELOPMENT OR WORKING PHASE
The client communicates what he or she thinks, feels, know, and perceive in response to
questions from the nurse.
Effective development of the interview demands that the nurse use communication techniques
that make both parties feel comfortable and serve the purpose of the interview.
The nurse elicits the clients comments about major biographic data, reasons for seeking care,
health of present health concern, past health history, family history, and review of body systems
for current health problems, lifestyle and health practices, and development level.
The nurse and client collaborate to identify the clients problems and goals.
3) CLOSING OR SUMMARY PHASE
The nurse terminates the interview when the needed information has been obtained.
The closing is important for maintaining the rapport and trust and for facilitating future
interactions.
The nurse summarizes information obtained during the working phase and validates problems
and goals with the client.
Also identifies and discusses possible plans to resolve the problem (nursing diagnosis and
collaborative problems) with the client.
TYPES OF COMMUNICATION
1) NONVERBAL COMMUNICATION is as important as verbal communication.

Guidelines to Make the Most Nonverbal Communication
a) Listen attentively and make eye contact frequently.
b) Use reassuring gestures, (nodding of head) to encourage the patient to keep talking.
c) Watch for nonverbal clues that indicate the patient is uncomfortable or unsure about how to
answer a question.
d) Be aware of your own nonverbal behaviors that might cause the patient to stop talking or
become defensive.
e) Observe the patient closely to see if he understands each question.
Influences in Nonverbal Communication
a) Appearance
b) Demeanor somebodys behavior, manner, or appearance, especially as it reflects on character.
c) Posture
d) Facial expression
e) Attitude
2) VERBAL COMMUNICATION is essential to a client interview.
- GOAL to elicit as much data about the clients health status as possible.
TYPES OF QUESTIONS
Open-ended questions
Often begin with How and What
Important because they require more than one-word response from the client, and therefore,
encourage description.
Closed-ended questions
Elicit yes-or-no answers or one-to-two word responses.
Limit the development the nurse-patient rapport.
Ex. Do you ever get short breath?
Neutral questions
A question the client can answer without direction or pressure from the nurse, is open-ended,
and is used in nondirective interviews.
Ex. How do you feel about that?
Leading questions
By contrast, is usually closed, used in a directive interview, and thus directs the clients answer.
Ex. You will take your medicine, wont you?
OTHER TECHNIQUE
1. Silence
2. Facilitation
- Please continue, go on, uh-huh
- Shows that you are interested in what hes saying.
3. Confirmation
- Helps ensure that you and the patient are on the same track.
- Helps to clear misconceptions that you or the patient might have.
4. Reflection
- Repeating something the patient has just said
- To help you obtain more specific information
5. Clarification
- When information is vague or confusing.
- Doing so gives the patient an opportunity to explain his statement.
6. Summarization
- Ensures that the data you have collected are accurate and complete
- Signals that the interview is about to end.
7. Conclusion
- Gives the opportunity to gather his thoughts and make pertinent final statements.
COMMUNICATION TO AVOID:
Nonverbal communication to avoid
a) Excessive or Insufficient Eye Contact
b) Distraction and Distance
c) Standing
Verbal communication to avoid
a) Biased or Leading questions
b) Rushing through the interview
c) Reading the questions
INITIATING THE INTERVIEW:
o Set the proper environment
o Overcoming language barriers
o Dealing with a culturally different patient
o Time
o Seating arrangement
o Distance
SPECIAL CONSIDERATION DURING THE INTERVIEW:
a) Gerontologic variations in communication
b) Cultural variation in communication
c) Emotional variation in communication
INTERVIEW TIPS:
To make the most of your patient interview, create an environment in which the patient feels
comfortable. Also, use the following technique to ensure effective communication.
1. Select a quite, private setting.
2. Choose terms carefully and avoid using medical jargon.
3. Speak slowly and clearly.
4. Use effective communication techniques, such as silence, facilitation, confirmation, reflection, and
clarification.
5. Use open-ended and close-ended questions as appropriate.
6. Use appropriate body language
7. Confirm patient statements to avoid misunderstanding.
8. Summarize and conclude with Is there anything else?