M ETHODS OF D ATA C OLLECTION

The nurse collects information through the following meth- ods: observation, interview, health history, symptom analysis, physical examination, and laboratory and diagnostic data.

These approaches require systematic use of the assessment skills discussed in the following text.

Observation

The nurse uses the skill of observation to carefully and attentively note the general appearance and behavior of the client. These observations occur whenever there is contact with the client and include factors such as client mood, inter- actions with others, physical and emotional responses, and any safety considerations. Observation helps the nurse deter- mine the client’s status, both physical and mental. By care- fully watching the client, the nurse can detect nonverbal cues that indicate a variety of feelings, including presence of pain, anxiety, and anger. Observational skills are essential in detecting the early warning signs of physical changes (e.g., pallor and sweating).

Interview

An interview is a therapeutic interaction that has a specific purpose. The nurse interviews for a variety of reasons throughout the nurse-client relationship, including data collec- tion, teaching, exploration of the client’s feelings or concerns, and provision of support. Effective interviewing depends on the nurse’s knowledge and ability to skillfully elicit informa- tion from the client using appropriate techniques of commu- nication. Observation of nonverbal behavior during the interview is also essential to effective data collection.

I

^NTERVIEW

P

^REPARATION The interview is more pro- ductive if the nurse has an opportunity to prepare for the inter- action. Such preparation includes review of the client’s medical records, conversations with other health care team members (e.g., personnel in emergency departments or long-term care facilities), and research of the presenting medical diagnosis.

This information can be useful in obtaining the client’s relevant history and formulating a current needs assessment.

I

NTERVIEW

S

TAGES Since the assessment interview often occurs at the beginning of a nurse-client relationship, it is helpful to begin the process with an orientation phase. Dur- ing this period introductions are made, rapport is established, and roles are defined. The first few minutes of the nurse- client meeting may give an indication of the type of inter- viewing needed, so it is important that the nurse employ active listening skills. There are three phases to an interview:

introduction, working, and closure.

Introduction Stage.

The introduction stage of the inter- view establishes the goals for the interaction. The primary goal of the assessment interview is the collection of data about the client. In this phase of the interview, the purpose and use of the data collection should be discussed. For exam- ple, the nurse might state, ‘‘I need to talk to you for a few

T

ABLE

6-1 Sample Application: Types of Data

DATA TYPE OF DATA

Charlene Rhodes, age 47, has come to the clinic after ‘‘passing out’’

twice in the last 2 days. She tells the nurse that she becomes

‘‘lightheaded’’ after almost any type of activity. She has experienced some nausea since yesterday and vomited after eating breakfast this morning. She also tells the nurse that she is very nervous about these occurrences because she remembers her mother having similar symptoms when the mother suffered from a brain disorder. The nurse observes that the client’s gait is unsteady and her skin is pale. The client also has large bruises on her right arm and the right side of her face, which she states occurred when she fell.

Subjective Report of fainting Complaint of dizziness Nausea

Verbalization of anxiety Self-reported fall Objective Vomiting Unsteady gait Pale skin

Bruises on right side of face and right arm

Delmar/Cengage Learning

NURSING PROCESS HIGHLIGHT

Assessment

Sources of Data

Mrs. Palmer, age 76, was admitted to the hospital following a stroke. She is responsive but unable to speak or move extremities on the right side. Her daughter, who lives next door, is present at the bed- side. What would be the best source of data in this situation?

minutes about your health so that we can better plan your care.’’ Adequate time and privacy should be allowed for the interview so that the client feels free to share any information that may be relevant. The parameters of confidentiality must be clearly explained to the client; see Chapter 12 for more in- formation on confidentiality. The nurse should also inform the client about the approximate duration of the interview.

The client is more likely to respond freely if the inter- view environment provides comfort and privacy and if rap- port exists between the client and the nurse. The nurse should sit (if possible), establish eye contact with the client, and listen attentively. It is the nurse’s responsibility to note nonverbal messages that may indicate that the client is uncomfortable, tired, or preoccupied with other matters. If any of these situations occur, it might be necessary to com- plete the interview at a later time. For example, if the client is guarding an incision and verbalizing discomfort or is extremely anxious about an impending procedure, only essential data are collected and the comprehensive interview is postponed until immediate needs have been met.

Working Stage.

The working stage of the interview focuses on the details of data collection. The scope of the assessment interview depends on the type of assessment to be conducted (e.g., comprehensive or focused). The inter- view may be structured and formal (used in situations when a large amount of information needs to be obtained) or unstructured and informal (used in interactions that focus on a specific area of concern to the client). The nurse should be familiar with the specific assessment format used by the health care agency so that attention can be focused toward the client rather than the form itself.

The interview generally begins with questions about bio- graphical and other nonthreatening information. The client’s reason for seeking health care is also addressed early in the work- ing phase. Information is usually gathered from the general to the specific, with details about intimate or potentially embarrass- ing topics reserved until later in the interview. The Nursing Checklist provides guidelines for interview preparation.

Techniques used during the interview will be deter- mined by the setting and purpose of the interview. A com- prehensive interview that seeks to identify problems and

concerns is facilitated by open-ended questions, while an interview that focuses on specific details about a presenting problem will be facilitated by direct, closed questions. For example, an emergency setting would likely employ more direct, closed questions, while admission to a long-term care facility might require greater use of open-ended questions.

Closed questionsare questions that can be answered briefly or with one-word responses. For example, the ques- tion ‘‘Have you been in the hospital before?’’ is a closed question that can easily be answered by a one-word response.

Questions about the dates of and reasons for the hospitaliza- tions are also closed questions that require brief answers.

Open-ended questions are questions that encourage the client to elaborate about a particular concern or problem.

For example, the question ‘‘What led to your coming here today?’’ is open-ended and allows the client flexibility in response. Both closed and open-ended questions can be effective in collecting information; see the accompanying Nursing Process Highlight.

Closure Stage.

Closure is established in the introduction phase when approximate time parameters are set. As the interview session is concluding, the nurse should indicate this fact by stating that almost all the information needed has been obtained or that the time for the interview is almost over. This action allows the client an opportunity to present any other relevant information, and it avoids surprises when the interview terminates. During the closure phase, the nurse summarizes what was covered or accomplished during the interview and requests validation of perceptions with the cli- ent. If the nurse or the client feels that additional time is needed for further exploration of specific points discussed during this session, plans can be made for future interviews.

Health History

A primary focus of the data collection interview is the health history. Thehealth history is a review of the client’s func- tional health patterns prior to the current contact with a health care agency. While the medical history concentrates on symptoms and the progression of disease, the nursing health history focuses on the client’s functional health pat- terns, responses to changes in health status, and alterations in lifestyle. The health history is also used in developing the

NURSINGCHECKLIST

Preparing the Interview Environment

• Ensure adequate lighting.

• Maintain a comfortable room temperature.

• Select an environment that is as free of noise and distractions as possible.

• Maintain client privacy.

• Make sure that the interview is timed appropri- ately.

• Promote client comfort.

NURSING PROCESS HIGHLIGHT

Assessment

Interview Techniques: Questioning

Which questions—closed or open-ended—do you think will extract the most useful and complete infor- mation from the client? Under which circumstances would each type of question be best used?

plan of care and formulating nursing interventions. Following are elements of the health history:

• Demographic information

• Reason for seeking health care

• Client perception of health status

• Previous illnesses, hospitalizations, surgeries

• Client and family medical history

• Immunizations and exposure to communicable disease

• Allergies

• Current medications

• Developmental level

• Psychosocial history

• Sociocultural history

• Activities of daily living

• Review of systems

D

EMOGRAPHIC

I

NFORMATION Personal data include name, address, date of birth, gender, religion, race and ethnic origin, and occupation. This information may be useful in helping to foster understanding of a client’s perspective.

R

EASON FOR

S

EEKING

H

EALTH

C

ARE The client’s rea- son for seeking health care should be described in the client’s own words. For example, the statement ‘‘fell off four-foot ladder and landed on right shoulder; unable to move right arm’’ is the client’s actual report of the event that precipitated the need for health care. The client’s perspective is important because it explains what is significant about the event from the client’s point of view. It is also important to determine the time of the onset of symptoms as well as a complete symptom analysis.

C

LIENT PERCEPTION OF

H

EALTH

S

TATUS Perception of health status refers to clients’ opinions of their general health. It may be useful to ask clients to rate their health on a scale of 1 to 10 (with 10 being ideal and 1 being poor), to- gether with the clients’ rationales for their rating scores. For example, the nurse may record a statement such as the fol- lowing to represent the client’s perception of health: ‘‘Rates health a 7 on a scale of 1 (poor) to 10 (ideal) because he must take medication regularly in order to maintain mobility, but the medication sometimes upsets his stomach.’’

P

REVIOUS

I

LLNESSES

, H

OSPITALIZATIONS

,

AND

S

UR- GERIES The history and timing of any previous experiences with illness, surgery, or hospitalization are helpful in order to assess recurrent conditions. It is also helpful to anticipate responses to illness, since prior experiences often have an impact on current responses.

C

LIENT AND

F

AMILY

M

EDICAL

H

ISTORY The nurse needs to determine any family history of acute and chronic illnesses that tend to be familial. Health history forms will frequently include checklists of various illnesses that can be used as the basis of the questions about this aspect. The cli- ent should be instructed that family history refers to blood relatives. It is also helpful to indicate who the relative is in relation to the client (e.g., mother, father, sister).

I

MMUNIZATIONS AND

E

XPOSURE TO

C

OMMUNICABLE

D

ISEASE Any history of childhood or other communicable diseases should be noted. In addition, a record of current immunizations should be obtained. This is particularly im- portant with children; however, records of immunizations for tetanus, influenza, and hepatitis B can also be important for adults. If the client has traveled out of the country, the time frame should be indicated in order to determine incubation periods for relevant diseases. The client should also be asked about potential exposure to communicable diseases, such as tuberculosis.

A

LLERGIES Any drug, food, or environmental allergies should be noted in the health history. In addition to the name of the allergen, the type of reaction to the substance should be noted. For example, a client may report developing a rash or becoming short of breath. This reaction should be recorded. Clients may report an ‘‘allergy’’ to a medication because they developed nausea after ingesting it, which the nurse will recognize as a side effect that would not necessar- ily preclude administration of the drug in the future. A cli- ent’s sensitivity to a drug can also change over time. Severe reactions may occur even though the client has successfully taken the drug or experienced only mild reactions to the drug in the past.

C

URRENT

M

EDICATIONS All medications currently taken, both prescription and over the counter, are to be recorded by name, frequency, and dosage. Remind clients that this in- formation should include medications such as birth control pills, laxatives, and nonprescription pain relief medications.

Ask which, if any, herbal preparations the client uses. Pat- terns related to caffeine and alcohol intake and use of tobacco or recreational drugs should also be explored. Use of alternative or complementary treatment methods, including herbals, is often not shared by health care consumers. Some clients fear rejection or ridicule when divulging such informa- tion to health care providers. The nurse uses a sensitive, non- judgmental approach when assessing the client’s use of all healing practices.

D

EVELOPMENTAL

L

EVEL Knowledge of developmental level is essential for considering appropriate norms of behavior and for appraising the achievement of relevant developmental tasks. Any recognized theory of growth and development can

SAFETY FIRST

ASSESSMENT FOR ALLERGIES

It is essential that the nurse explore possible aller- gies prior to administering any medications. Allergic reactions can be life threatening and can occur even with very low dosages of medications.

be applied in order to determine whether clients are functioning within the parameters expected for their age group. For exam- ple, if the nurse uses Erikson’s stages of psychosocial develop- ment, evaluation of an adult client attaining the developmental task of generativity versus stagnation can be validated by a nurse’s statement such as ‘‘client prefers to spend time with his family; very involved in children’s school activities.’’

P

SYCHOSOCIAL

H

^ISTORY Psychosocial history refers to assessment of dimensions such as self-concept and self- esteem as well as usual sources of stress and the client’s abil- ity to cope (see Chapter 23). Sources of support for clients in crisis (such as family, significant others, religion, or sup- port groups) should be explored.

S

OCIOCULTURAL

H

ISTORY In exploring the client’s soci- ocultural history, it is important to inquire about the home environment, family situation, and client’s role in the family.

For example, the client could be the parent of three children and the sole provider in a single-parent family. The responsi- bilities of the client are important data by which the nurse can determine the impact of changes in health status and thus plan the most beneficial care for the client.

A

CTIVITIES OF

D

AILY

L

IVING The activities of daily liv- ing are a description of the client’s lifestyle and capacity for self-care. This information is useful both as baseline informa- tion and as a source of insight into usual health behaviors.

This database should include the following areas:

• Nutrition: Includes type of diet, foods eaten, and fluids consumed regularly; food preparation; the size of por- tions; and the number of meals per day. Food preferences and dislikes, as well as the client’s need for assistance in food preparation or eating, should also be determined.

• Elimination:Includes both urinary and bowel elimination frequency and patterns. Any recent changes or problems in these patterns should be noted.

• Rest and sleep: Includes the usual number of hours of sleep, number of hours of sleep needed to feel rested, sleep aids used, and the time within the day or night when sleep usually occurs. Any bedtime rituals (especially with children) should also be noted.

• Activity and exercise:Includes types and patterns of exer- cise in a typical day or week. If assistance is needed with activities such as walking, standing, or meeting hygienic needs, this information should be noted.

R

EVIEW OF

S

YSTEMS Thereview of systems(ROS) is a brief account from the client of recent signs or symptoms associated with any of the body systems. This allows the cli- ent an opportunity to communicate any deviations from nor- mal that have not been otherwise identified. The ROS relies on subjective information provided by the client rather than data from the physical examination. When a symptom is encountered, either while eliciting the health history or dur- ing the physical examination, the nurse should obtain as much information as possible about the symptom. Relevant data include:

• Location: The area of the body in which the symptom (such as pain) can either be pointed to or described in detail.

• Character: The quality of the feeling or sensation (e.g., sharp, dull, stabbing).

• Intensity:The severity or quantity of the feeling or sensa- tion and its interference with functional abilities. The sen- sation can be rated on a scale of 1 (very little) to 10 (very intense).

• Timing:The onset, duration, frequency, and precipitating factors of the symptom.

• Aggravating and alleviating factors:The activities or actions that make the symptom worse or better.

Physical Examination

The purpose of the physical examination is to make direct observations of any deviations from normal and to validate subjective data gathered through the interview. Baseline measurements are obtained, and physical examination techni- ques are used to gather objective data.

B

ASELINE

D

ATA Baseline data collection is the systematic organization of observations obtained during the physical ex- amination. The baseline becomes the basis for comparison and evaluation to establish the status of a client at a given point in time. Measurement of height, weight, and vital signs (temperature, pulse, respirations, and blood pressure) is im- portant for comparison with future measurements in order to judge the significance of any changes (progress or regres- sion) over time.

A

SSESSMENT

T

ECHNIQUES The physical examination incorporates the use of visual, auditory, tactile, and olfactory senses and the use of systematic assessment techniques. The use of visual, auditory, and tactile senses will be described with each of the specific assessment techniques. In addition, olfaction (sense of smell) is helpful in detecting characteristic odors as well as those associated with altered health states.

For example, presence of infection is sometimes first detected by a change in the characteristic odor of body fluids or drainage. The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation.

Inspection.

Inspection involves careful visual observa- tion. The client is observed first from a general point of view and then with specific attention to detail. For example, the nurse first observes for patterns of skin lesions and then focuses on the specific characteristics of individual lesions.

Instruments such as a penlight and otoscope are often used to enhance visualization. Effective inspection requires adequate lighting and exposure of the body parts being observed. Beginning nurses often feel self-conscious or embarrassed using the technique of inspection; however, most become comfortable with the technique over time.

Nurses must also be sensitive to the client’s feelings of embarrassment with the use of inspection and respond to