The methods of data gatherin are the following:
- The interview......Questioning technique
- The nursing history....Questioning technique
- The physical examination - --Observation and measurement
- The psychologic and mental health examination ----Psycho - Social measurement
- Laboratory Data
The Interview
Interview has been discussed under the following headings:
Interview has been discussed under the following headings:
- Definition
- Purposes
- Types
- Phases of Interview
Now let us discuss all about ‘Interview’, which is the first in the order of priority in normal circumstances.
i) Definition
It is a purposeful and goal-directed interaction between two persons, one acting as an interviewer and the other as interviewee.
ii) Purposes
a) To establish and maintain a positive and open relationship between client and nurse.
b) To create an opportunity for the nurse to observe the client’s behaviour and non-verbal communication.
c) To provide information to the client.
d) To gather information from the client.
e) To give counsel to the client regarding his problems.
f) To teach the client and his relatives regarding his condition and treatment.
iii)Types
Interview method can be classified as:
a) Problem seeking: To get data to find out client’s problems.
b) Problem solving: To help client to solve his problems. To find out whether the procedures have helped to solve his problems.
iv) Interviews can be classified as:
a) Directive: The interviewer asks a series of prepared questions. The answer can be ‘yes’ or ‘no’ or a few words. This method is used to get from client information such as his age, occupation, number of children, his habits, hobbies, etc.
b) Non-directive open ended interview: It leads to an open ended discussion between interviewer and interviewee. The interviewer directs the talks and the interviewee is made to talk much. e.g. asking for client’s past medical history,present conditions etc.
i) Definition
It is a purposeful and goal-directed interaction between two persons, one acting as an interviewer and the other as interviewee.
ii) Purposes
a) To establish and maintain a positive and open relationship between client and nurse.
b) To create an opportunity for the nurse to observe the client’s behaviour and non-verbal communication.
c) To provide information to the client.
d) To gather information from the client.
e) To give counsel to the client regarding his problems.
f) To teach the client and his relatives regarding his condition and treatment.
iii)Types
Interview method can be classified as:
a) Problem seeking: To get data to find out client’s problems.
b) Problem solving: To help client to solve his problems. To find out whether the procedures have helped to solve his problems.
iv) Interviews can be classified as:
a) Directive: The interviewer asks a series of prepared questions. The answer can be ‘yes’ or ‘no’ or a few words. This method is used to get from client information such as his age, occupation, number of children, his habits, hobbies, etc.
b) Non-directive open ended interview: It leads to an open ended discussion between interviewer and interviewee. The interviewer directs the talks and the interviewee is made to talk much. e.g. asking for client’s past medical history,present conditions etc.
Phases of Interview
The phases of interview are:
----- Preparation and Planning
----- Opening the interview
----- Conducting the interview
----- Closing the interview
----- Recording the interview.
a) Preparation and Planning: Before starting the interview, you should review the client’s past history chart, and care plan to learn about his past illnesses and treatments.Review the client’s present admission and hospitalization record. Consult with the physician regarding the client’s condition, symptoms and problems.Write the objectives of the interview and also write some of the questions to be asked to the patient.
After this, prepare the client, environment, and yourself for the interview. The place must be private and comfortable so that the client can relax.There should not be radio, television playing, and presence of other people.Close the doors and draw curtains for privacy. Avoid interruptions during interview.Do not conduct interview during visiting time or when he is due to receive a treatment.
Remove client’s physical discomfort, e.g., if he is thirsty give a drink, make him comfortable. Discomfort will distract him from his talk.You should be relaxed physically and psychologically. A comfortable chair, good lighting for taking notes. You should not be thinking of other matters and problems.You should concentrate on the interview.
b) Opening the Interview: Start the interview in a warm and friendly way. Otherwise client will withhold information. You should show care and concern. Address the client by his/her name. You introduce yourself and say the purpose of the interview and how the information gathered is going to be useful for his care. Can start with the question, “How are you at present?”
c) Conducting the Interview: During the interview focus on the questions,verbal and non verbal patterns of communication.
Questions
The types of questions to be asked —
Open questions, e.g. What reduces your pain?
Closed questions, e.g. Have you taken food?
Direct questions, e.g. Did you sleep well last night?
Indirect questions, e.g. Did sleep come to you last night?
Questions should be simple and short.
Ask one question at a time and give sufficient time for him to answer before asking the next question.
Use broad, indirect and open questions to begin with and then later on can ask closed questions.
Use words which he can understand. Use language according to age, education and background of the patient.
Use his own terms when wording questions.
Do not use words which will be of suggestive type, e.g., too many.
Avoid using ‘How’ and ‘Why’ questions as far as possible. If at all asked they should not sound as a threat.
Non-verbal Communication
You should look for non-verbal communication such as facial expression crying, gestures of anxiety, anger, fear, sorrow etc. You should also understand your own nonverbal communication. Your gestures should convey warmth and understanding and not fatigue,boredom, irritation, anger, etc. through your facial expression. Nodding, sympathetic facial expression, looking at him with attention, touching him etc. can convey your warmth to him.
d) Closing the Interview: Close the interview in a warm and friendly manner. Summarise the content of the interview at the closing time.
e) Recording the Interview: Inform the client that you are going to write down information which will be needed to plan his care. Write only points. Your writing should not interfere with your listening. Can use a prepared assessment form for recording.
Interviewing Clients with Special Problems
a) Client with Serious Illness: If he can talk ask a few short questions -get information from close family members.
b) Client with Hearing Loss: Face the client when talking so that he can watch your lips and expression, use gestures, use short sentences and phrases.
c) Dysphasia (Problem of Speech): In motor aphasia patient can understand but he may not be able to talk. This may be partial or complete. If partial, ask questions which may require answers “Yes” or “No” or with a nod. Give him time to answer. Be empathetic. He may be frustrated because he cannot answer you. If he cannot talk, make no comments about him to others. He can hear though he cannot talk.
d) Language Barrier: You can use gestures and observe the client’s gestures and nonverbal behaviours. Get an interpreter if available.
e) Depressed Client: He may be distracted and preoccupied. May give slow and brief answers.It may be difficult to interview him. Be kind and firm. Ask short questions.
f) Conditions of the Larynx: Give paper and pencil or a magic state for him to answer questions.
The Nursing History or Health History
Definition
A Nursing History describes the client’s total health condition and his physical, mental and emotional reactions to illness and the changes in his daily life activities and life-style as a result of the illness.Whereas, a Medical History focuses on the client’s symptoms and process of the disease.Thus, while Medical and Nursing histories are based upon similar content, they focus upon different aspects of the client’s life.
Purposes
The Nursing History is a valuable assessment tool. Because it:
a) is the first stage of identifying health problems and needs of client and planning for immediate and long-term patient care.
b) establishes a basis of information on which nursing diagnosis and plans for treatment can be made.
c) helps to establish rapport and interrelationship with the client and his family.
d) allows us to observe the client’s ability to communicate and his general behaviour.
e) gives the client an opportunity to express all his health problems and health needs,doubts, worries, feelings etc.
f) is a written document about client’s health condition, treatment and care process.
g) includes clients past and present health condition.
h) helps to measure the progress of client’s health condition.It is easy to gather all information if we have a structured outline or format for collecting client’s health history. A format is suggested here.
a) Client with Serious Illness: If he can talk ask a few short questions -get information from close family members.
b) Client with Hearing Loss: Face the client when talking so that he can watch your lips and expression, use gestures, use short sentences and phrases.
c) Dysphasia (Problem of Speech): In motor aphasia patient can understand but he may not be able to talk. This may be partial or complete. If partial, ask questions which may require answers “Yes” or “No” or with a nod. Give him time to answer. Be empathetic. He may be frustrated because he cannot answer you. If he cannot talk, make no comments about him to others. He can hear though he cannot talk.
d) Language Barrier: You can use gestures and observe the client’s gestures and nonverbal behaviours. Get an interpreter if available.
e) Depressed Client: He may be distracted and preoccupied. May give slow and brief answers.It may be difficult to interview him. Be kind and firm. Ask short questions.
f) Conditions of the Larynx: Give paper and pencil or a magic state for him to answer questions.
The Nursing History or Health History
Definition
A Nursing History describes the client’s total health condition and his physical, mental and emotional reactions to illness and the changes in his daily life activities and life-style as a result of the illness.Whereas, a Medical History focuses on the client’s symptoms and process of the disease.Thus, while Medical and Nursing histories are based upon similar content, they focus upon different aspects of the client’s life.
Purposes
The Nursing History is a valuable assessment tool. Because it:
a) is the first stage of identifying health problems and needs of client and planning for immediate and long-term patient care.
b) establishes a basis of information on which nursing diagnosis and plans for treatment can be made.
c) helps to establish rapport and interrelationship with the client and his family.
d) allows us to observe the client’s ability to communicate and his general behaviour.
e) gives the client an opportunity to express all his health problems and health needs,doubts, worries, feelings etc.
f) is a written document about client’s health condition, treatment and care process.
g) includes clients past and present health condition.
h) helps to measure the progress of client’s health condition.It is easy to gather all information if we have a structured outline or format for collecting client’s health history. A format is suggested here.
Recording of the Nursing History
Nursing history has to be written in such a way that the information can be used whenever necessary. For that a few suggestions are given:
1) Write the information Accurately by writing accurate grammar, spelling and tense.
2) Writing the information Briefly. Sentences do not have to be complete as long as they are giving correct and clear meaning.
3) Write Clear information. Avoid long sentences, technical phrases and uncommon words.
Use only standard medical abbreviations. Never use a word unless you understand its meaning. Handwriting must be legible.
4) Descriptions must be to-the-point. Avoid the use of words which need interpretation, e.g.,good, bad, thin, fat etc.
5) Do not give your Explanation of client’s behaviour as, he is “depressed”,“uncooperative”, or “overanxious”. That may be misleading. Only describe his behaviour,as, “he is not talking to anyone, turning his face towards the wall and crying silently”.
6) Write only the Factual information, which can be checked if necessary.
7) Gentle probing type of communication helps to bring our specific information.
Activity 1
Select a patient from Medical/surgical ward and take the nursing history. Against areas not applicable you can write N.A. Summarize at the end the most relevant data assessed. Record the data in Nursing History format
Nursing history has to be written in such a way that the information can be used whenever necessary. For that a few suggestions are given:
1) Write the information Accurately by writing accurate grammar, spelling and tense.
2) Writing the information Briefly. Sentences do not have to be complete as long as they are giving correct and clear meaning.
3) Write Clear information. Avoid long sentences, technical phrases and uncommon words.
Use only standard medical abbreviations. Never use a word unless you understand its meaning. Handwriting must be legible.
4) Descriptions must be to-the-point. Avoid the use of words which need interpretation, e.g.,good, bad, thin, fat etc.
5) Do not give your Explanation of client’s behaviour as, he is “depressed”,“uncooperative”, or “overanxious”. That may be misleading. Only describe his behaviour,as, “he is not talking to anyone, turning his face towards the wall and crying silently”.
6) Write only the Factual information, which can be checked if necessary.
7) Gentle probing type of communication helps to bring our specific information.
Activity 1
Select a patient from Medical/surgical ward and take the nursing history. Against areas not applicable you can write N.A. Summarize at the end the most relevant data assessed. Record the data in Nursing History format
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