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 encounter with 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. Introduction 3. 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 for subjective 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 time 6. 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 comments 2. 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 data 3. 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 symptoms P Provokes What makes it worse/better? Q Quality What does pain feel like? R Region Where? S Severity Scale of 1-10 T Time When, how often? 4. Past Health 5. 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 1. Using silence 2. Accepting 3. Giving recognition 4. Giving broad openings 5. Restating 6. Focusing 7. Exploring 8. Voicing doubt Non-Therapeutic 1. Giving reassurance 2. Rejecting 3. Approving/Disapprovin 4. Giving advice 5. Probing 6. Defending 7. Belittling feelings 8. Aggreeing/Disagreeing

9. Present reality

9. Requesting explanation