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Interview techniques

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Question
Answer
What is subjective data   Information from the patient/ what the patient tells you  
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What is objective data   Information you gather about the patient/ what you see  
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What are the 4 different types of assessments   Initial comprehensive assessment, partial/ongoing/time-lapsed assessment, focused/problem oriented assessment, emergency assessment  
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Describe an initial comprehensive assessment   Basic head to toe assessment of the patient, goiing through entire body  
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Describe a partial or ongoing assessment   A reassessment of what you already know (I.e. Blood pressure is high, medicate patient & reasses to see if change occurred)  
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Describe a focused/ problem oriented assessment   Focus on the problem at hand. (I.e. Blood pressure just increased, why did it increase? * does not have to be the issue the patient initially came for  
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Describe the emergency assessment   A quick judgement assessment (I.e CPR for someone not breathing)  
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What are the 5 phases of the nursing process   Assess, diagnose, plan, implement, evaluate  
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Phases of the interview   Introductory, working, summary& closing  
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What is involved in the introductory phase of interview   Introduce yourself & state your position, explain purpose of interview, discuss the types of questions that will be asked, explain the reason for taking notes, assure the client all info is confidential, ensure patient is comfortable, develop trust  
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What does the working phase of the interview entail   Gathering data about the patient such as: biographic data, reasons for seeking care, history of present health concern/past health history&family health history, review of body system,lifestyle & health practices, identify problem& develop a plan  
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What does the summary and closing phase of the interview entail   summarize and reiterate info obtained during the interview, validate problems and goals with the client, identify and discuss possible plans of resolution, make sure to inquire about any other questions/concerns the patient may have  
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What are some key points to remember when interviewing a client   set the environment, have your pans in order, use techniques like clockwork, use open ended questions, include close ended questions, review at end of assessment  
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What happens when a patient complains about pain during an interview   C.O.L.D.S.P.A  
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What does C.O.L.D.S.P.A stand for?   Character (Describe pain), Onset (When did it begin), Location (Where), Duration (How long does it last/How long has it been going on), Severity (How severe is it 1-10), Pattern (What makes pain better or worse), Associated factors (What else hurts)  
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What is the 5th Vital sign   Pain  
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Collection of objective data is what?   Anything you can see, smell, hear, feel such as: physical characteristics, body functions, appearance, behavior, measurements, results of lab tests  
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What are some assessment techniques used to gather objective data   inspect, palpate, percuss, auscultate  
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What is involved in the inspection technique   you are looking, listening, and smelling. You are observing the size, shape, color, symmetry, location and any abnormalities  
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What is a palpation   A gentle touch; palpate for moisture, temperature, texture, turgor, tenderness, lumps  
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What is a percussion   Involves tapping the skin with your fingertips to vibrate underlying tissues or organs; typically on the back or stomach; listen for sounds *The thicker or firmer the tissue the quieter the sound is  
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What does it mean to auscultate   To listen; listen to sounds our body makes and determining if those sounds are normal or not  
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What is considered to be groundwork   Infection control- use standard precaution during entire exam environment- privacy, adequate lighting, fall precaution equipment- make sure they're properly cleaned and working; be prepared  
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What are some key points on preparing your patient   If possible start with an empty bladder, make sure the patient is properly positioned, always give a thorough explanation of what you will be doing to alleviate anxiety, assess each age group appropriately (if patient is too young explain to parent)  
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