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Retdem Interview Guide

interview/reviewer

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Glaiza Godalle Torres
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16 views2 pages

Retdem Interview Guide

interview/reviewer

Uploaded by

Glaiza Godalle Torres
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Nursing Interview Guide to Collect Subjective Data from the Client

Question Findings
1. Lumps or lesions on head or neck that do not
heal or disappear.
2. Difficulty moving head or neck.

3. Facial or neck pain or frequent headaches.

4. Dizziness, lightheadedness, spinning sensation,


or loss of consciousness.

Past History

Previous head or neck problems/trauma/injury (surgery,


medication, physical or radiation therapy) results

Family History

1. Family history of head and/or neck cancer.

2. Family history of migraine headaches.

Lifestyle and Health Practices

1. Do you smoke or chew tobacco? Amount?


Secondhand smoke?
2. Do you wear a helmet or hard hat?

3. Typical posture when relaxing, during sleep,


and when working.
4. Type of recreational activities.

5. Satisfaction with appearance

Gather equipment (gloves, penlight or flashlight,


small glass of water, stethoscope).

Explain procedure to client.

Head and Face

1. Inspect head for size, shape, and configuration.

2. Palpate head for consistency while wearing


gloves.
3. Inspect face for symmetry, features, movement,
expression, and skin condition.
4. Palpate temporal artery for tenderness and
elasticity.
5. Palpate temporomandibular joint for range of
motion, swelling, tenderness, or crepitation by
placing index finger over the front of each and
asking client to open mouth. Ask if client has history
of frequent headaches.
Neck

1. Inspect neck while it is in a slightly extended


position (and using a light) for position,
symmetry, and presence of lumps and masses.
2. Inspect movement of thyroid and cricoid
cartilage and thyroid gland by having client
swallow a small sip of water.
3. Inspect cervical vertebrae by having client flex
neck.
4. Inspect neck range of motion by having client
turn chin to right and left shoulder, touch each
ear to the shoulder, touch chin to chest, and lift
chin to ceiling.
5. Palpate trachea by placing your finger in the
sternal notch, feeling to each side, and palpating
the tracheal rings.
6. Palpate the thyroid gland.

7. Auscultate thyroid gland for bruits if the gland is


enlarged (use bell of stethoscope).
8. Palpate lymph nodes for size/shape,
delimitation, mobility, consistency, and
tenderness (refer to display on characteristics of
lymph nodes).

1. Preauricular nodes (front of ears)


2. Postauricular nodes (behind the ears)
3. Occipital nodes (posterior base of skull)
4. Tonsillar nodes (angle of the mandible, on the
anterior edge of the sternocleidomastoid muscle)
5. Submandibular nodes (medial border of the
mandible); do not confuse with the lobulated
submandibular gland.
6. Submental nodes (a few centimeters behind the
tip of the mandible); use one hand
7. Superficial cervical nodes (superficial to the
sternomastoid muscle)
8. Posterior cervical nodes (posterior to the
sternocleidomastoid and anterior to the trapezius
in the posterior triangle)
9. Deep cervical chain nodes (deep within and
around the sternomastoid muscle)
10. Supraclavicular nodes (hook fingers over
clavicles and feel deeply between the clavicles
and the sternomastoid muscles)

Analysis of Data

1. Formulate nursing diagnoses (wellness, risk,


actual).
2. Formulate collaborative problems.

3. Make necessary referrals.


4.

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