{"id":669,"date":"2019-05-22T20:52:21","date_gmt":"2019-05-23T00:52:21","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/categories-and-influencing-factors\/"},"modified":"2024-06-05T16:26:01","modified_gmt":"2024-06-05T20:26:01","slug":"categories-and-influencing-factors","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/categories-and-influencing-factors\/","title":{"raw":"Categories and Influencing Factors","rendered":"Categories and Influencing Factors"},"content":{"raw":"<h2>Categories<\/h2>\r\nCategories of the complete subjective health assessment (as illustrated in <strong>Figure 4<\/strong>) vary depending on the framework you follow, but generally include:\r\n<ul>\r\n \t<li>Introductory information: Demographic and biographic data.<\/li>\r\n \t<li>Main health needs (reasons for seeking care).<\/li>\r\n \t<li>Current and past health.<\/li>\r\n \t<li>Mental health and mental illnesses.<\/li>\r\n \t<li>Functional health.<\/li>\r\n \t<li>Preventive treatments and examinations.<\/li>\r\n \t<li>Family health.<\/li>\r\n \t<li>Cultural health.<\/li>\r\n<\/ul>\r\n[caption id=\"attachment_668\" align=\"aligncenter\" width=\"500\"]<img class=\"wp-image-668\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess.jpg\" alt=\"Computer with the categories of the complete subjective health assessment on the screen.\" width=\"500\" height=\"427\" \/> <strong>Figure 4<\/strong>: Categories of the Subjective Health Assessment[\/caption]\r\n\r\nYou begin the assessment with an introduction followed by collecting information about demographic and biographic data and then, main health needs. Afterwards, there is no specific order in which these categories must be assessed. Often it depends on the client\u2019s main health needs or reasons for seeking care. Sometimes it depends on the natural flow of conversation that occurs with the client. Usually, you assess sections that involve sensitive questions as well as cultural health towards the end when you have had the opportunity to develop a level of trust with the client. Remember, when introducing yourself state your full name, designation, and pronouns, and then ask the client what name and pronouns you should use to refer to them. It is important not to use the term \"preference\" when referring to pronouns and gender as these are not preferences.\r\n\r\nIn addition to these categories, you may incorporate subjective questions specific to each of the body\u2019s systems; this phase is called a <strong>[pb_glossary id=\"741\"]Review of the Systems[\/pb_glossary]<\/strong>. These questions give you insight into each body system (e.g., skin, eyes, cardiovascular, musculoskeletal). Depending on the client\u2019s response and the reporting of <strong>[pb_glossary id=\"743\"]cues[\/pb_glossary]<\/strong> that prompt your concern, you may probe further with more specific questions. In other readings, you will learn about subjective questions related to each body system.\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\"><span style=\"color: #ffffff\">Clinical Tip<\/span><\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nAlways ask one question at a time.\r\n\r\n<\/div>\r\n<\/div>\r\n<h2>Influencing Factors<\/h2>\r\nInfluencing factors constitute common situational issues that can arise during a subjective data assessment. Always consider <strong>factors that may influence how you ask questions<\/strong> and the validity and reliability of the subjective data collected. These situational factors can be difficult to both assess and address in certain cases (see <strong>Table 2<\/strong>).\r\n\r\n&nbsp;\r\n\r\n<strong>Table 2<\/strong>: Influencing factors and strategies\r\n<table style=\"border-collapse: collapse;width: 100%;height: 232px\" border=\"0\">\r\n<tbody>\r\n<tr style=\"height: 14px\">\r\n<td style=\"width: 32.0558%;height: 14px\"><strong>Factors<\/strong><\/td>\r\n<td style=\"width: 67.9442%;height: 14px\"><strong>Strategies<\/strong><\/td>\r\n<\/tr>\r\n<tr style=\"height: 14px\">\r\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;\r\n\r\nClients may be hyperaware of the situation and wonder why you are asking certain questions.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"width: 67.9442%;height: 14px\">\r\n<ul>\r\n \t<li>Begin by sharing with the client why you are asking these types of questions.<\/li>\r\n \t<li>Encourage the client to ask you questions if they are uncertain about why certain information is being sought.<\/li>\r\n \t<li>Normalize sensitive questions by stating: \u201cI ask all clients about X so that I can better understand the context of their health and illness.\u201d<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 14px\">\r\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;\r\n\r\nClients may downplay or exaggerate what they tell you.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"width: 67.9442%;height: 14px\">\r\n<ul>\r\n \t<li>Seek clarification.<\/li>\r\n \t<li>Reframe the questions you ask.<\/li>\r\n \t<li>Paraphrase what the client says and ask if you have captured their meaning correctly.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 14px\">\r\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;\r\n\r\nClients may withhold information because they fear sharing information, feel judged by sharing certain information, and\/or have a condition that is often stigmatized.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"width: 67.9442%;height: 14px\">\r\n<ul>\r\n \t<li>Emphasize confidentiality.<\/li>\r\n \t<li>Introduce sensitive questions later in the interview once you have established a therapeutic and trusting relationship.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 14px\">\r\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;\r\n\r\nClients may not be fully conscious or oriented due to a physical injury, a mental health condition, a traumatic event, or substance use.<\/td>\r\n<td style=\"width: 67.9442%;height: 14px\">\r\n<ul>\r\n \t<li>It is important to be patient and give clients time to think and respond to your questions.<\/li>\r\n \t<li>You may need to delay asking some questions until the client begins recovering.<\/li>\r\n \t<li>If appropriate, ask other people who can share information about the client to corroborate it.<\/li>\r\n<\/ul>\r\n<strong>Note<\/strong>: With a client who is under the influence of a substance, it is important to avoid prejudice, remain nonjudgmental, treat them with respect, speak slowly and clearly with simple language, provide a safe environment for them, and continue to monitor while observing changes in behaviour and level of consciousness.<\/td>\r\n<\/tr>\r\n<tr style=\"height: 162px\">\r\n<td style=\"width: 32.0558%;height: 162px\">&nbsp;\r\n\r\nClients may function at a developmental age (as opposed to actual age). Developmental age is the age that a client functions at on a cognitive, physical, emotional, and social level. You need to consider this factor with all ages across the lifespan.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"width: 67.9442%;height: 162px\">\r\n<ul>\r\n \t<li>Tailor your language and tone of voice to the client\u2019s developmental age.<\/li>\r\n \t<li>Always use a respectful and professional tone.<\/li>\r\n \t<li>Create space for others to be involved and\/or invite a care partner to be present.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n&nbsp;\r\n<div class=\"textbox textbox--key-takeaways\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\">Points of Consideration<\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nIt is important to document who provides the subjective data. Usually, subjective data is provided by the client (<strong>[pb_glossary id=\"755\"]primary source[\/pb_glossary]<\/strong>), but in some situations it may be collected from the client\u2019s chart, family members, friends, co-workers, care partners, or interpreters\r\n(<strong>[pb_glossary id=\"757\"]secondary sources[\/pb_glossary]<\/strong>). In certain cases, the client may be unable to speak or share information, or may speak a different language than you, or be unconscious. Additionally, a care partner (such as a family member) may need to provide subjective data for a newborn or a client with developmental, cognitive, or mental health states that prohibit them from speaking.\r\n\r\n<\/div>\r\n<\/div>\r\n<header>\r\n<h2 class=\"entry-title\">Reflective questions<\/h2>\r\n<\/header>\r\n<ol>\r\n \t<li>What strategies should you use to address influencing factors of common situational issues that can arise during a complete subjective data assessment?<\/li>\r\n \t<li>How should you begin a complete subjective health assessment?<\/li>\r\n \t<li>What are the categories of a complete subjective health assessment?<\/li>\r\n<\/ol>\r\n<strong style=\"font-family: 'Cormorant Garamond', serif;font-size: 1.602em\">Test Yourself<\/strong>\r\n<p style=\"text-align: center\">[h5p id=\"6\"]<\/p>","rendered":"<h2>Categories<\/h2>\n<p>Categories of the complete subjective health assessment (as illustrated in <strong>Figure 4<\/strong>) vary depending on the framework you follow, but generally include:<\/p>\n<ul>\n<li>Introductory information: Demographic and biographic data.<\/li>\n<li>Main health needs (reasons for seeking care).<\/li>\n<li>Current and past health.<\/li>\n<li>Mental health and mental illnesses.<\/li>\n<li>Functional health.<\/li>\n<li>Preventive treatments and examinations.<\/li>\n<li>Family health.<\/li>\n<li>Cultural health.<\/li>\n<\/ul>\n<figure id=\"attachment_668\" aria-describedby=\"caption-attachment-668\" style=\"width: 500px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-668\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess.jpg\" alt=\"Computer with the categories of the complete subjective health assessment on the screen.\" width=\"500\" height=\"427\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess.jpg 1000w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess-300x256.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess-768x656.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess-65x56.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess-225x192.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2019\/05\/categorieshealthassess-350x299.jpg 350w\" sizes=\"auto, (max-width: 500px) 100vw, 500px\" \/><figcaption id=\"caption-attachment-668\" class=\"wp-caption-text\"><strong>Figure 4<\/strong>: Categories of the Subjective Health Assessment<\/figcaption><\/figure>\n<p>You begin the assessment with an introduction followed by collecting information about demographic and biographic data and then, main health needs. Afterwards, there is no specific order in which these categories must be assessed. Often it depends on the client\u2019s main health needs or reasons for seeking care. Sometimes it depends on the natural flow of conversation that occurs with the client. Usually, you assess sections that involve sensitive questions as well as cultural health towards the end when you have had the opportunity to develop a level of trust with the client. Remember, when introducing yourself state your full name, designation, and pronouns, and then ask the client what name and pronouns you should use to refer to them. It is important not to use the term &#8220;preference&#8221; when referring to pronouns and gender as these are not preferences.<\/p>\n<p>In addition to these categories, you may incorporate subjective questions specific to each of the body\u2019s systems; this phase is called a <strong><button class=\"glossary-term\" aria-describedby=\"669-741\">Review of the Systems<\/button><\/strong>. These questions give you insight into each body system (e.g., skin, eyes, cardiovascular, musculoskeletal). Depending on the client\u2019s response and the reporting of <strong><button class=\"glossary-term\" aria-describedby=\"669-743\">cues<\/button><\/strong> that prompt your concern, you may probe further with more specific questions. In other readings, you will learn about subjective questions related to each body system.<\/p>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\"><span style=\"color: #ffffff\">Clinical Tip<\/span><\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p>Always ask one question at a time.<\/p>\n<\/div>\n<\/div>\n<h2>Influencing Factors<\/h2>\n<p>Influencing factors constitute common situational issues that can arise during a subjective data assessment. Always consider <strong>factors that may influence how you ask questions<\/strong> and the validity and reliability of the subjective data collected. These situational factors can be difficult to both assess and address in certain cases (see <strong>Table 2<\/strong>).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Table 2<\/strong>: Influencing factors and strategies<\/p>\n<table style=\"border-collapse: collapse;width: 100%;height: 232px\">\n<tbody>\n<tr style=\"height: 14px\">\n<td style=\"width: 32.0558%;height: 14px\"><strong>Factors<\/strong><\/td>\n<td style=\"width: 67.9442%;height: 14px\"><strong>Strategies<\/strong><\/td>\n<\/tr>\n<tr style=\"height: 14px\">\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;<\/p>\n<p>Clients may be hyperaware of the situation and wonder why you are asking certain questions.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"width: 67.9442%;height: 14px\">\n<ul>\n<li>Begin by sharing with the client why you are asking these types of questions.<\/li>\n<li>Encourage the client to ask you questions if they are uncertain about why certain information is being sought.<\/li>\n<li>Normalize sensitive questions by stating: \u201cI ask all clients about X so that I can better understand the context of their health and illness.\u201d<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 14px\">\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;<\/p>\n<p>Clients may downplay or exaggerate what they tell you.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"width: 67.9442%;height: 14px\">\n<ul>\n<li>Seek clarification.<\/li>\n<li>Reframe the questions you ask.<\/li>\n<li>Paraphrase what the client says and ask if you have captured their meaning correctly.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 14px\">\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;<\/p>\n<p>Clients may withhold information because they fear sharing information, feel judged by sharing certain information, and\/or have a condition that is often stigmatized.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"width: 67.9442%;height: 14px\">\n<ul>\n<li>Emphasize confidentiality.<\/li>\n<li>Introduce sensitive questions later in the interview once you have established a therapeutic and trusting relationship.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 14px\">\n<td style=\"width: 32.0558%;height: 14px\">&nbsp;<\/p>\n<p>Clients may not be fully conscious or oriented due to a physical injury, a mental health condition, a traumatic event, or substance use.<\/td>\n<td style=\"width: 67.9442%;height: 14px\">\n<ul>\n<li>It is important to be patient and give clients time to think and respond to your questions.<\/li>\n<li>You may need to delay asking some questions until the client begins recovering.<\/li>\n<li>If appropriate, ask other people who can share information about the client to corroborate it.<\/li>\n<\/ul>\n<p><strong>Note<\/strong>: With a client who is under the influence of a substance, it is important to avoid prejudice, remain nonjudgmental, treat them with respect, speak slowly and clearly with simple language, provide a safe environment for them, and continue to monitor while observing changes in behaviour and level of consciousness.<\/td>\n<\/tr>\n<tr style=\"height: 162px\">\n<td style=\"width: 32.0558%;height: 162px\">&nbsp;<\/p>\n<p>Clients may function at a developmental age (as opposed to actual age). Developmental age is the age that a client functions at on a cognitive, physical, emotional, and social level. You need to consider this factor with all ages across the lifespan.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"width: 67.9442%;height: 162px\">\n<ul>\n<li>Tailor your language and tone of voice to the client\u2019s developmental age.<\/li>\n<li>Always use a respectful and professional tone.<\/li>\n<li>Create space for others to be involved and\/or invite a care partner to be present.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--key-takeaways\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\">Points of Consideration<\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p>It is important to document who provides the subjective data. Usually, subjective data is provided by the client (<strong><button class=\"glossary-term\" aria-describedby=\"669-755\">primary source<\/button><\/strong>), but in some situations it may be collected from the client\u2019s chart, family members, friends, co-workers, care partners, or interpreters<br \/>\n(<strong><button class=\"glossary-term\" aria-describedby=\"669-757\">secondary sources<\/button><\/strong>). In certain cases, the client may be unable to speak or share information, or may speak a different language than you, or be unconscious. Additionally, a care partner (such as a family member) may need to provide subjective data for a newborn or a client with developmental, cognitive, or mental health states that prohibit them from speaking.<\/p>\n<\/div>\n<\/div>\n<header>\n<h2 class=\"entry-title\">Reflective questions<\/h2>\n<\/header>\n<ol>\n<li>What strategies should you use to address influencing factors of common situational issues that can arise during a complete subjective data assessment?<\/li>\n<li>How should you begin a complete subjective health assessment?<\/li>\n<li>What are the categories of a complete subjective health assessment?<\/li>\n<\/ol>\n<p><strong style=\"font-family: 'Cormorant Garamond', serif;font-size: 1.602em\">Test Yourself<\/strong><\/p>\n<p style=\"text-align: center\">\n<div id=\"h5p-6\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-6\" class=\"h5p-iframe\" data-content-id=\"6\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Chapter 1 - Page: Categories and Influencing Factors\"><\/iframe><\/div>\n<\/div>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"669-741\" hidden><p>Questions specific to each body system.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"669-743\" hidden><p>Symptoms or signs that signal a potential concern that may need to be investigated further (e.g., headaches)<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"669-755\" hidden><p>Data provided by the client.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"669-757\" hidden><p>Data provided by someone other than the client.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-sa"},"chapter-type":[49],"contributor":[73,75,74,76,77,78],"license":[54],"class_list":["post-669","chapter","type-chapter","status-publish","hentry","chapter-type-numberless","contributor-jlapum-f2a1dpqc2w","contributor-michelle-hughes-etb2hoqgw0","contributor-oona-st-amant-trtymitjjy","contributor-paul-petrie-y9lu7fmlm2","contributor-sherry-morrell","contributor-sita-mistry","license-cc-by-sa"],"part":673,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/669","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":8,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/669\/revisions"}],"predecessor-version":[{"id":2600,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/669\/revisions\/2600"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/673"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/669\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=669"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=669"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=669"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=669"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}