Data Collection II (Video) | JoVE (2024)

7.3: Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family, environmental, psychosocial, and spiritual history.

The nurse collects a nursing history by interviewing the patient. A nursing interview is structured communication and is an effective way of gathering data. Before the interview, obtaining the patient's consent is mandatory. The interview phases include the preparatory phase, the introductory phase, the working phase, and the termination phase.

During the preparatory phase, the nurse prepares and identifies the patient to be interviewed, establishes an interview timeline, and selects a distraction-free place to meet.

Then, during the introductory phase, the nurse-patient relationship begins as the nurse states the interview's purpose. The patient is informed where the data is stored, the usage, and who can access the data. During the working phase, the nurse collects all information needed to create the subjective database. The database's completeness, accuracy, and relevance depend on the nurse's interviewing and communication techniques.

Successful interviews conclude carefully. During the termination phase, the nurse informs the patient that the interview is ending. As the interview ends, the nurse and the patient will review the data gathered, highlighting key points and ensuring all information is accurate. Ensuring accurate, essential data is collected is critical for the nurse-patient relationship and continuing with a patient-focused plan of care.

Tags

Nursing History Patient's Health Status Care Plan Initial Assessment Comprehensive History Biographical Information Reasons For Seeking Health Care Present And Past Health History Medications Family History Environmental History Psychosocial History Spiritual History Nursing Interview Structured Communication Data Gathering Patient's Consent Interview Phases Preparatory Phase Introductory Phase Working Phase Termination Phase Nurse-patient Relationship Data Storage And Usage

Data Collection II (Video) | JoVE (2024)

FAQs

What are the 4 phases of the nursing interview? ›

The interview phases include the preparatory phase, the introductory phase, the working phase, and the termination phase. During the preparatory phase, the nurse prepares and identifies the patient to be interviewed, establishes an interview timeline, and selects a distraction-free place to meet.

What are the four phases of the nurse-patient relationship? ›

Phases of the nurse-client relationship

It's important to understand the phases of this relationship, because each phase requires different tasks and interpersonal interactions. The phases of the nurse-client relationship are pre-orientation, orientation, working, and termination.

What is the purpose of data collection in nursing? ›

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment.

What are the types of data in nursing process? ›

Subjective and objective data are two important types of information that professionals use to inform organizational decisions, improve systems and evaluate short- or long-term progress. In nursing, subjective and objective data are both essential for evaluating patient health and success.

What is the 3 phase interview process? ›

Knowing what to expect can help reduce interview anxiety. Most job interviews can be broken down into three phases: Introduction, Getting to Know You, and Closing.

What are the 5 steps or phases of the nursing process? ›

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

What are the 4 phases of care? ›

Table 1
Phases of careEthical elements
1. Recognition of need (caring about)1. Attentiveness
2. Willingness to respond to (take care of) a need2. Responsibility
3. Direct action (care-giving)3. Competence
4. Reaction to the care process (of the care receiver)4. Responsiveness

What are the four phases of caring? ›

The four phases of care are caring about, taking care of, caregiving and care receiving. Caring about involves 'noting the existence of a need and making an assessment that this need should be met' (Tronto, 1993, p. 106).

What are the 4 phases of Hildegard Peplau theory? ›

What are the four stages of the Interpersonal Relations Theory according to Hildegard Peplau? The four stages are Orientation, Identification, Exploitation, and Resolution, outlining the evolving relationship between a nurse and a patient.

What is data collection for patient care? ›

What Is Data Collection in Healthcare? Data collection in healthcare is simply the process of gathering, analyzing, and using information harvested from various data sources. Data collection may serve a multitude of purposes and help a provider achieve a number of goals.

What part of the nursing process where data collection is gathered? ›

Assessment. The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.” A registered nurse uses a systematic method to collect and analyze patient data.

What is the nurse's primary source for data collection? ›

A patient is considered the primary source of subjective data. Secondary sources of data include information from the patient's chart, family members, or other health care team members.

In which stage does the nurse collect data? ›

The first phase of the nursing process is assessment. It involves collecting, organizing, validating, and documenting the clients' health status. This data can be obtained in a variety of ways.

What are the major nursing assessments you will use to collect data? ›

Nursing Process
  • Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history)
  • Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)

What is an example of data in nursing? ›

What is an example of objective data? Objective data is data directly observed by the nurse. This could be something measurable, such as temperature or blood pressure, or something observed with the senses, such as a rash or a cough.

What are the 4 phases of the interview? ›

Any job interview can be broken down into four general stages: introductions, broad questions and answers, position-related questions, and the conclusion.

What is the sequence of the nursing interview? ›

-Phases of the Interview: Introductory Phase -The nurse introduce himself to the client. -The nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential.

What are the four components of a clinical interview? ›

  • Purpose of the interview.
  • Your setting.
  • Your Theoretical Orientation.
  • Client's problems or needs. Body Checklist.

References

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