Data Collection II

A nursing history captures and records the patient's biographical information and their complete health status, including present and past health, family, environmental, psychosocial, and spiritual history. This comprehensive record ensures a care plan evolves to meet the patient's individual needs and plays a significant role in the assessment process.

The nursing interview consists of four phases: preparatory, introductory, working, and termination. During the preparatory phase, the nurse identifies the patient and selects a distraction-free location. The introductory phase establishes the nurse-patient relationship and ensures confidentiality. The working phase collects subjective data using communication techniques. The termination phase concludes the interview after required data is collected.

During the introductory phase, the nurse-patient relationship is established and the interview's purpose is stated. The patient must be assured of confidentiality and informed about where data is stored, how it will be used, and who can access it. This phase builds trust and sets expectations for the interview process.

Patient variables such as anxiety, pain, language difficulty, prior negative healthcare experiences, and unrealistic expectations can affect the interview outcome positively or negatively. The nurse's awareness of these factors and use of effective communication techniques help ensure accurate data collection despite these potential barriers.

During the working phase, nurses collect subjective data using effective communication techniques, particularly asking open-ended questions. The completeness, accuracy, and relevance of the subjective database depend on the nurse's interviewing and communication skills to gather all information needed for patient-focused care.

Obtaining the patient's verbal consent before the interview is mandatory and establishes respect for patient autonomy. Consent ensures the patient understands the interview's purpose, data usage, and storage procedures, which builds trust and supports the nurse-patient relationship essential for accurate data collection.

During the termination phase, the nurse informs the patient that the interview is ending and reviews the data gathered together. The nurse and patient highlight key points and ensure all information is accurate, which is critical for continuing with a patient-focused plan of care and formulating and validating nursing diagnosis.