HEALTH ASSESSMENT LESSON 2 Fhardina Leigh Yap’s Notes

LESSON # 2 - Provides the objective database

COLLECTING SUBJECTIVE DATA 2. Observation
Communication - Use of sense to collect data
- Is the process of sharing information and - Assess patient and envi
meaning, and sending and receiving  Facial expression, color changes,
messages breathing prob
Nonverbal messages  Grimacing, guarding, diaphoresis
- More accurate than verbal  Eye contact
- Should coincide with verbal data  Tone of voice and flow of speech
Nonverbal Behavior  Position
1. Vocal Cues or Paralinguistic  Voluntary and involuntary move
- Quality of the voice and its inflections, 3. Interview
tone, intensity, and speed when - Purposeful conversation between
speaking nurse and patient
Reflects: feelings, physiological and  Gather data
psychological problems  Establish rapport
2. Action Cues or Kinetics  Teach patient
- Body movements that convey a  Health promotion
message Therapeutic use of Self
Reflects: mood, underlying physiologic - Use of interpersonal skills with
and psycho problems empathy acceptance, and recognition
 Hand gestures  Close-ended que
 Posture  Open-ended que
 Eye contact Directive Interview – structured and
 Facial expressions controlled by nurse
3. Objective Cues Nondirective interview – controlled by
- Dress and grooming as well as patient
furnishing or possessions METHODS OF DATA COLLECTION
4. Personal Space 1. Introductory Phase
- Maintained for the person to feel  Self intro
comfortable  Purpose of interview
Public Space – 12 feet or more  Time frame
Social-Consultative Space – 4-12 away 2. Working Phase
Personal Distance – 18 inches – 4ft  Data collection
Intimate – 0-18 inches  Longest phase
5. Touch 3. Termination phase
- Means of communication  Summary
- Helps obtain an accurate,  Follow-up plans
comprehensive health history
- Makes physical assessment quicker INTERVIEW TECHNIQUES
COLLECTING OF DATA 1. Affirmation/Facilitation
Subjective Data - Acknowledging patient’s response
- Covert and not measurable  Nodding, sitting up, leaning
- Symptoms forward, encourage your patient
to continue
Objective Data 2. Silence
- Overt and measurable - Allow the patient to collect her or his
- Signs thoughts before responding
GATHERING OF SUBJECTIVE DATA - Gives nurse more time to think
3. Clarifying
Primary Data – from patient - If the nurse is unsure about what the
Secondary – anyone aside from patient patient said, rephrase what she said
METHODS OF DATA COLLECTION and ask to clarify
1. Physical Assessment 4. Restating
- Use of IPPA
HEALTH ASSESSMENT LESSON 2 Fhardina Leigh Yap’s Notes

- Helps clarify and validate what patient

said
5. Active Listening
- Pay attention, maintain eye contact,
listen to what patient tells
- It conveys interest and acceptance
6. Broad or General Openings
- Hear what is important to the patient
“What would you like to talk about?”
7. Reflection
- Allow nurse to acknowledge patient’s
feelings
8. Informing
- Giving info to patient to be involved in
his healthcare decisions
9. Redirecting
10. Focusing – allows you to hone in on a
specific area
11. Sharing perceptions – nurse give
interpretation of what has been said
12. Sequence events – help place the event
in proper order
13. Suggesting – presenting alternative
ideas
14. Presenting reality – help examine what
has already been said
15. Summarizing – useful for conclusion
of major sections

INTERVIEW TECHNIQUES
1. Letting family members answer – having
the patient describe things in her own
2. Asking more than one ques at a time
3. Not allowing enough response time
4. Using medical jargons
5. Assuming
6. Taking patient’s response personally
7. False reassurance
8. Persistent questioning
9. Changing the subject
10. Jumping to conclusions