HEALTH ASSESSMENT LECTURE (LESSON 1-3)

LESSON 1: NURSING PROCESS - Enhances nursing efficiency by

standardizing nursing process
Nursing - Facilitates documentation of care
(WHO) - Provides a unity of language to the
- Nursing encompasses autonomous nursing profession
and collaborative care of - Nursing process is economical
individuals of all ages, families, - Stresses the independent function of
groups and communities, sick or well nurses
and in all settings. It includes the - Increases care quality through the
promotion of health, the prevention use of deliberative actions
of illness, and the care of ill, disabled - Provide continuity of care and
and dying people prevent duplication
(ANA, 2010)
- The protection, promotion, and Characteristics
optimization of health and - Interpersonal and collaborative
abilities, prevention of illness and - Open and flexible
injury, alleviation of suffering - Client-centered
through the diagnosis and treatment - Goal-directed, outcome focused
of human responses and advocacy - Universally acceptable
in the care of individuals, families, - Cyclic and dynamic
communities and populations. - Emphasizes feedback
Emphasis is placed on “diagnosis
and treatment of human responses” Nursing Skills
based on “accurate client 1.) Cognitive
assessments,” including how - Problem solving and decision
effective nursing interventions are making
“to promote health and prevent - Critical thinking
illness and injury” 2.) Technical
Nursing Process - Includes hands on skills
- A systematic problem-solving needed to perform
approach used to identify, prevent, procedures
and treat actual or potential health 3.) Interpersonal
problems and promote wellness - Verbal and non-verbal
- A systematic way to plan, responses
implement, and evaluate care for - Communication
individuals, families, groups, and
communities Phases (ADPIE)
- Continuous, cyclical process that 1.) Health Assessment
revolves around the patient - First and most important step
in the nursing process
Benefits - Deliberate and systematic
- Provides an orderly and systematic collection of information
method for planning and providing about a patient to determine
care his or her current and past

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 health and functional status - An ongoing process
and his/her present and past integrated with nursing care
coping patterns to determine the status of a
- Systematic and continuous specific problem identified in
collection, organization, an earlier assessment
validation, and - Identifies new or overlooked
documentation of data problems
- The nurse gathers - E.g., endorsements
information about a patient’s ● Emergency assessment
psychological, physiological, - Occurs during any
sociological, and spiritual physiologic or psychological
status through observation, crisis of the client to identify
interviewing, physical the life-threatening problems
examination, health records, ● Time-lapsed assessment
and family members - Occurs several months after
the initial assessment to
compare the client’s current
status to baseline data
previously obtained
- E.g., laboratory or
appointments of discharged
patients

Purpose of Assessment Assessment Skills (IOPI)

- To establish baseline information on 1.) Interview
the client - A conversation with purpose
- To determine the client’s normal to get or give information, to
function teach and provide support
- To determine the client’s risk for 2.) Observation
dysfunction - An active acquisition of
- To determine the client’s strengths information from a source
- To provide data for the diagnosis which employs the use of
phases senses
- Verbal and nonverbal
Types of Assessment (IPET) 3.) Physical Examination
● Initial assessment: - A systematic data collection
- Triage method by inspection,
- Performed within a specified palpation, percussion,
time after admission to auscultation
establish a complete 4.) Intuition
database for problem - Uses of insight, instinct, and
identification, reference, and clinical experience to make
future comparison clinical judgments about the
● Problem-focused assessment: clients

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 laboratory and diagnostic
Activities in the Assessment Process analyses)
(COVD)
1.) Collect Data
- Establishing baseline data
- Noting subjective and
objective data from the client
- The process of gathering
information about the
patient’s health status that
begin with the first patient Factors that may Impede Client Data
contact, using method/skills Collection
of assessment
- It must be systematic and
continuous to prevent the
omission of significant data
and reflect patient’s
changing/unusual health
2.) Organize Data
status
- Grouping the data using
- Baseline data: refers to all
head to toe model, systemic
the information about the
review etc
patient
- Collect information must be
- Methods: interview,
organized to be useful
observation, history
- Data clustering is a useful
collection, physical
tool to identify issues
examination, results of lab
- To obtain and document
and diagnostic tests
assessment data
- Types of data: subjective
systematically, the nurse
(what the person states/ what
uses an organized
the patient verbalizes;
assessment framework
symptoms; itching, pain,
which can be modified
feelings, perceptions) and
according to patient’s
objective (what the nurse
physical status
observes; can be
- Nursing conceptual models:
measurable; signs; vital
gordon’s functional health
signs, skin changes, patient
pattern framework, orem’s
behavior)
self deficit model, Roy’s
- Sources of data: Primary
adaptation model
source (the client is the
primary source of data) and
Secondary source (family
members, health
professionals, health records,

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 - Ensure complete information
- Ensure that objective and related
subjective data agree
- Obtain additional information that
may have been missed
- Differentiate between cues and
inferences
- Avoid jumping to conclusions to
identify problems

4.) Document/Record Data

- Documents subjective data in
client own words and
objective using medical
terms, key, abbreviations
3.) Validate Data
- The nurse records the data
- Double checking the data to
to complete the assessment
confirm accuracy
phase
- The act of double checking
- Assessment data must be
or verifying data to confirm
recorded and reported
that they are accurate and
- Accurate and complete
factual
documentation is essential
- Validation prevents
and should include all data
omissions,
collected about the patient’s
misunderstandings, and
health status
incorrect inferences and
- Assessment takes place in
conclusions
all realms: physical mental,
- Not all data requires
emotional, cultural, spiritual,
validation (age, height,
social, environmental
weight)
- Cues are subjective or
2.) Nursing Diagnosis
objective data that can be
- Uses NANDA (The North
directly observed by the
Americal Nursing Diagnosis
nurse; that is, what the
Association)
patient says or what the
- Describes only problems that
nurse can see, hear, feel,
can be handled by nurses
smell, or measure
- Describes a human response
- Inferences are the nurse’s
- Differs from the medical
conclusion or interpretation
diagnosis but should
of the cues (red, hot, swollen
complement it
incision site: the nurse
Problem Identification or Clinical
makes the inference that the
Judgment
incision site is infected.)
● An opinion that the nurse makes
based on the clinical data obtained
Validating Data helps the nurse to:

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 ● Allows the nurse to identify, develop in a vulnerable
associate and interpret the signs and individual, family, or
symptoms of a given condition community
- Two-part statements do not
Steps in Making the Nursing Diagnosis include defining
● Interpret and validate patient data; characteristics
analyze all data - E.g., risk for impaired skin
● Identify the patient’s problems and integrity
strengths 3.) Wellness Nursing Diagnosis
● Formulate and validate the nursing - Clinical judgment about a
diagnoses, both actual and potential person’s, family’s or
diagnoses community’s motivation and
● Prioritize a list of appropriate nursing desire to increase wellbeing
diagnoses (no patient has only one as expressed in the
problem in only one realm) readiness to enhance
specific health behaviors and
Benefits can be used in any health
● Gives nurses a common language state
● Can create a standard for nursing - One part statement includes
practice diagnostic label
● Promotes identification of - E.g., readiness for enhanced
appropriate goals or correct choice family coping
● Provides a quality improvement 4.) Syndrome Nursing Diagnosis
base - A clinical judgment
describing a specific cluster
of nursing diagnoses that
occur together, and are best
addressed together through
similar interventions
- E.g., post trauma syndrome

Nursing Diagnosis vs. Medical Diagnosis

Types of Nursing Diagnosis 1.) Nursing Diagnosis
1.) Actual Nursing Diagnosis - Clinical judgment about
- Identifies the current problem individual, family, or
that is present at the time of community responses to
the assessment actual and potential health
- Based on th epresence of problems or life processes
signs and symptoms - The goal of a nursing
- E.g., ineffective airway diagnosis is to identifu actual
clearance and potential responses
2.) Risk Nursing Diagnosis - Nurses treat the problem
- Describes human responses within the scope of
to health conditions that may independent nursing practice

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 - May change from day to day - Involves anticipation and
as the patient’s responses planning for the client’s
change needs after discharge
2.) Medical Diagnosis
- Identification of a disease Elements of Planning
condition based on a specific - Prioritize the problems/nursing
evaluation of physical signs, diagnosis
symptoms, history, diagnostic - Formulate goals/desired outcomes:
tests, and procedures Short term (to resolve in few hours
- The goals of a medical or days) & Long term (to resolve
diagnosis is to identify th over weeks or months)
ecause of an illness or injury - Select nursing interventions
and design a treatment plan - Write nursing interventions
- Physician directs treatment
for medical diagnosis Characteristics of Planning
remains the same as long as
the disease is present SMART
- Systematic
3.) Planning - Measurable
- Planning is to formulate the - Attainable
way to manage the problem - Realistic
Goal Setting - Time-bounded
● Formulation of guidelines that MACROS
establish the proposed course of - Measurable and observable
nursing action in the resolution of - Achievable & time limited
nursing diagnoses and the - Client-centred
development of the client’s plan of - Realistic
care - Outcome written
- Specific/systematic
Steps in Planning
1.) Initial Planning Rules for Writing Goals
- Done by the nurse who ● Always start with one realistic time
performs admission frame
assessment in order to ● Followed by the phrase: “the client
prioritize problems, identify will demonstrate…” or “the first part
goals and correlate nursing of the goal needs to reflect the
care to resolve the problems nursing diagnosis”
2.) Ongoing Planning ● This is followed by AEB and 2-3 goal
- Involves continuous updating criteria
of the client’s plan of care - Goal criteria must reflect
- Every nurse who cares for desired changes in the signs
the client is involved in and symptoms listed
ongoing planning - Criteria must be observable
3.) Discharge Planning and/or measurable

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 ● Teach
4.) Implementation
5.) Evaluation
Nursing Intervention
● Provides the actual nursing activities Results/Effects
and client responses ● The judgment of the effectiveness of
● Consists of doing and documenting nursing care to meet client goals or
the activities that are the specific expected outcome
nursing actions needed to carry out ● Determines the success or
the interventions or nursing orders effectiveness of the whole nursing
process and the decision either to
Implementation Process continue, modify or repeat the
1.) Reassessing the Patient process is dependent on evaluation
- Helps to identify the
proposed nursing actions Purposes
and are still appropriate for or ● Determine client’s behavior and
the patient’s level of wellness response
2.) Reviewing and Revising the Existing ● Assess the collaboration of the client
Nursing Care Plan and health team
- If the client status has ● Compare the client’s response with
changed then modify the outcome criteria
care plan ● Appraise the extent to which client’s
3.) Organizing Resources and Care goals
Delivery ● Identify the errors in the plan of care
- Ensures efficiency of care ● Monitor the quality of nursing care
delivered
4.) Anticipating and Preventing Components of Evaluation
Complications ● Collect the data
- Requires critical thinking ● Compare the data
skills ● Relate nursing activities
5.) Implementing Nursing Interventions ● Continue modify or terminate the
- Direct care or indirect care care plan
● Draw conclusions
Three Components
● Must use an action verb While documenting the evaluation
● State where, what, how, how much, phase, the nurse can draw one of the
and how for three possible conclusions….
● Time element- when, how often, how
long 1.) Goal Met
- The client response is the
Four Types same as the desired
● Assess outcomes
● Care 2.) Goal Partially Met
● Manage

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 -Either a short-term goal was
achieved but the long term
was not
- The desired outcome was
partially attained
3.) Goal Not Met
- The client response is not the
same as desired outcomes

Nursing Process vs. Scientific Method

Nursing Process Scientific Method

Assessment Ask Questions

Diagnosis Identify Problems

Planning Hypothesis

Implementation Experiment

Evaluation Analyze/Conclusion

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 ● Note special circumstances, such as
LESSON 2: HEALTH HISTORY use of interpreter
GUIDELINES
2.) Reason for seeking care / Chief
Purpose complaint
1.) to collect data about physical, ● CC - Chief Complaint
mental, and social well-being of ● Brief, spontaneous statement in
client person’s own words
2.) To get a clear picture of the client’s ● Comprises of:
health status and health related - Symptom
problems - Duration
3.) To determine the cause and extent ● “What prompted you to seek consult
of disease now?”
4.) To determine the nature of treatment ● E.g., “Chest pain for two hours”,
required for client “colds for 2 days now, and just
5.) To collect data systematically getting worse”
6.) To get a holistic (complete) view of
the client 3.) History of Past Illness (HPI)
7.) Recognizes and affirms what the ● Well clients: a short statement about
client is doing right the general state of health
8.) Determines and corrects what the ● Ill clients: chronological reason for
client is doing wrong seeking care from the time the
9.) To formulate appropriate nursing symptom started until the time the
care plan care was sought
● The chronology can be taken in one
Health History Sequence of two ways:
1.) Biographical data - Reverse chronology: from
- Name the current state of the
- Age problem back to its origin
- Gender - Forward chronology:from the
- Address origin of the symptom leading
- Marital status to the current status
- Occupation ● Describe the condition that you are
- Birthplace experiencing from the earliest time
- Phone number that it occurred to the present
- Race ● 10 Critical characteristics of chief
- Ethnic origin complaint
● Source and reliability of history (1) Location: be specific; ask
● Note who furnishes the information person to point the location
(client, significant other, caseworker) (2) Radiation: Spreading of the
● Judge how reliable the information symptom of other CC from its
seems original location; “does the
● Determine willingness to pain move to another part of
communicate the body”

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 (3) Quality: describes the way (3) Region/Radiation: where is
the symptom feels to the it? Does it spread anywhere?
patient; burning, stabbing, (4) Severity (Quantity): Scale of
pinching throbbing 1-10, is it getting better,
(4) Quantity: depicts severity, worse, or the same?
volume, number, or extent of (5) Timing: When, how long, how
CC; minor (self intervention), often?
moderate (medication), (6) Understanding: Meaning and
severe (sleep/rest), and Impact to patient
small, medium, large 4.) Past Health History (PHH)
(5) Associated Manifestations: ● Provides information on the patient’s
S & Sx that accompany the health status from birth to present
CC; “Besides headache are ● Past health events are important
you experiencing any other because they may have residual
symptoms? What are they?” effects on the current health state
(6) Aggravating Factors: ● Previous experience with illness may
factors that worsen the give clues to:
severity of the CC; “Have you - How a person responds to
done anything that makes illness
your headache worse?” - Significance of illness to
(7) Alleviating Factors: factors him/her
that decrease the severity of ● Medical History:
CC; “have you done anything - Comprises all medical
that decreases the severity of problems that the patient has
the headache? What?” experienced during
(8) Timing: Onset (gradual or adulthood and their
sudden), Duration sequelae, or aftermath
(continuous or intermittent), - Includes chronic illnesses as
frequency (no. of times the well as serious episodic
CC occurs) illnesses
(9) Setting: where was the ● Adult illnesses/Serious Chronic
person when the symptoms Illnesses:
started?; “where were you - Document previously
when your headache diagnoses illness
started?” - E.g., asthma, diabetes,
(10) Meaning and Impact: hypertension, heart disease,
significance of the CC to the HIV/AIDS, hepatitis,
patient and the impact the sickle-cell anemia, cancer,
CC has on the patient seizure disorder
● HPI Analysis of the Symptom ● Surgical History:
(1) Provocative/Palliative: what - Type of Surgery (Minor or
makes symptoms Major), date of surgery, name
better/worse of surgeon, name of hospital,
(2) Quality: How intense/severe?

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 how client recovered, special individualized care to a
considerations patient
● Allergies: - Down syndrome, a patient
- Carefully explore all patient with paraplegia and a
allergies (meds, animals, sociopathic patient all have
insect bites, food, latex, and unique needs
environmental allergens - “Do you have any disability
- Document history of allergy or special need? Describe.
noting: What type of limitations does
- Allergen: drug, contact, or this disability place on you”
environmental agent ● Blood Transfusions
- Reaction: rash, itching, - The chance of contracting an
runny, nose, watery eyes, infectious disease from a
DOB blood transfusion is greatest
● Current Medications: in patients who receive large
- Document all medications number of transfusions
taken - Such as patients with
- Prescription drugs, hemophilia, oncology
over-the-counter patients and trauma victims
medications, vitamins and - “Have you ever received
other supplements, birth blood transfusions? When?”
control pills, antacids ● Childhood Illnesses
● Communicable diseases - What illnesses were
- Hepatitis C, HIV, AIDS, experienced by client as a
Pulmonary tuberculosis, child (e.g., rubeola, rubella,
Varicella, measles, mumps, varicella, pertussis, parotitis,
rubella, polio, diphtheria, strep throat)
rheumatic fever - Ask about serious illnesses
● Injuries & Accidents that may have sequel in later
- Vehicular accidents years (e.g., rheumatic fever,
- Fractures scarlet fever, poliomyelitis)
- Penetrating wounds ● Past Health History
- Head injuries - Immunization Status
- Burns - Note complete vaccination
- NOI: Nature of Incident history clients (MMR, DPT,
- POI: Place of Incident OPV/IPV, varicella Hep A &
- DOI: Date of Incident B, Mengigococcal, HPV,
- TOI: Time of Incident Influenza, and
● Special needs: Pneumococcal Vaccine
- The awareness of any - Note last TT immunization
cognitive, physical, or and last Mantoux test
psychosocial disability is ● Last examination Date
essential to providing - Determine last examination
date including:

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 - Physical exam, dental exam,
visual exam, hearing test,
ecg and other diagnostics
● Obstetric History
- Done specifically for women
- LMP
(1) Gravidity
(2) Term ● Pedigree/Genogram:
(3) Preterm - A graphic family tree that
(4) Abortions uses symbols to depict
(5) Living gender, relationship, and age
● Obstetric History of immediate blood relatives
- Complete Pregnancies: in at least three generations
course of pregnancy, labor & - Health of close family
delivery, gender, weight, members is equally important
condition of infant, to highlight since prolonged
postpartum course contact with any
- Incomplete pregnancies: communicable disease or
Duration (AOG), environment hazard can
spontaneous, induced affect the person’s health

5.) Family Health History (FHH)

● Records the health status of the
patient, as well as that of immediate
blood relatives
● An accurate family history will
highlight diseases and conditions for
which a person may be at increased
risk 6.) Review of Systems
● Contains: ● Social History
- List of family members - Explores information about
(genogram) the patient’s lifestyle that can
- Social support affect health
- Occurrence of diseases in - Includes alcohol use, drug
the family (CHD, HPN, DM, use, tobacco use, domestic
CVA, Obesity, Blood and intimate partner
disorders, cancer, addiction, violence, sexual practice,
mental illness, kidney travel history, work and home
disease, seizure disorders, environment, hobbies and
tuberculosis leisure activities, stress,
education, economic status,
religion, and roles &
relationships
7.) Functional Assessment

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 Hours of sleep
Usual Daily Schedule Purposes of Interview
Habits 1.) Gather complete and accurate
Modes of Relaxation data about the person’s health state
Diet 2.) Establish rapport and trust so the
Environmental Hazards person feels accepted and thus free
Occupational History to share all relevant data
Economic status and resources 3.) Teach the person about the health
Usual source of health care state so that the person can
Emergency plan participate in identifying problems
4.) Build rapport for a continuing
therapeutic relationship
LESSON 3: THE PATIENT INTERVIEW 5.) Begin teaching for health
promotion and disease prevention
Interview
● A meeting between the nurse and Approaches
patient
● Collects subjective data: What the
Directive Interview Nondirective Interview
client perceives about his or her
state of health Highly structured “Rapport- building
● A planned communication or interview”
conservation with a purpose
Elicits specific Client controls the
information purpose, subject, and
Goals pacing of interview
● Record a complete health history
● Achieve optimal health for the client Nurse establishes Gather data on
the purpose and patient’s needs
Focuses controls interview
1.) Establishing Rapport Gather information
- A trusting relationship with at a limited time
the patient elicits accurate
and meaningful information
2.) Gathering Information
Types of Interview Questions
- Gathering information on the
1.) Closed Questions
patient’s developmental,
- Yes-no questions
psychological, physiologic,
- When, who, where, what
sociocultural, and spiritual
questions
statuses to identify deviations
- Used in directive interview
that can be treated with
2.) Open-ended Questions
nursing and collaborative
- Non-directive interview
interventions or strengths
- What, how questions
that can be enhanced
- Clients can explore,
through nurse-patient
elaborate, clarify, illustrate
collaboration
feelings and thoughts

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 3.) Neutral Questions They require less May not reveal
- Client can answer without Closed effort from the how the
Questions interviewee interviewee feels
pressure
4.) Leading Questions May be less Do not allow
- Directs clients to answer threatening, do interviewee to
not require volunteer possibly
questions explanations and valuable info
- Clients have less opportunity justifications
to decide
Takes less time May inhibit
communication
and convey lack of
interest by the
Closed VS. Open-ended Questions interviewer

Info can be Interviewer may

asked for sooner dominate
Type Advantages Disadvantages that it would be interview with
volunteered questions
Lets interviewee Takes more time
do the talking Responses are
easily
Interviewer is Only brief answers documented
able to listen and may be given
Open- observe Questions are
Ended easy to use and
Questions Easy to answer Valuable info may can be handled
and be withheld by unskilled
non-threatening interviews

May reveal Often elicits more

interviewee’s lack info than
of info, necessary
misunderstandin Open-Ended Closed/Direct
g, and
stereotypes Use for narrative Use for specific
info information
Can provide info Responses
interviewer may require
not ask for psychologic
Calls for long Calls for
insight and paragraph answers one-to-two-word
sensitivity from the answers
interviewer
Elicits feelings, Elicits cold facts
Can reveal opinions, ideas
interviewee’s
feelings
Builds and Limits rapport and
Can convey enhances rapport leaves reaction
interest and trust neutral

“Tell me about your “Are your

Type Advantages Disadvantages headaches” headaches
bearable or
Questions and May provide too unbearable?”
answers can be little info and
more effectively require follow up
controlled questions Phases of Patient Interview

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1.) Pre-orientation Phase seated as eye level with each
- The nurse reviews the other)
medical record before - Steps:
meeting the patient. This (1) Address the client by
information may assist the stating his/her title
nurse with conducting the followed by last name
interview by knowing some of (e.g., Ms. Sapico)
the patient’s biographical (2) Introduce yourself
information that is already and your role in the
documented agency
- If the patient has been in the (3) State the reason for
system for some time, it may the interview
reveal additional information. (4) Ask open-ended
For example, the record may questions
indicate that the patient has 3.) Working Phase
difficulty hearing in one ear - The nurse elicits that
2.) Orientation Phase patient’s comments about
- The nurse should provide a major biographic data,
personal introduction and reasons for seeking care,
explains the purpose of the history of present health
interview, discusses the concern, past health history,
types of questions that will be family history, review of body
asked, explains the reason systems for current health
for taking notes, and assures problems, lifestyle and health
the client that confidential practices, and developmental
information will remain level
confidential - The nurse then listens,
- Demographic data should be observes cues, and uses
collected by asking focused critical thinking skills to
questions. General interpret and validate
information can be gathered information received from the
by open-ended patient.
communication techniques - The nurse and patient
- Nurse also makes sure that collaborate to identify the
the patient is comfortable patient’s problems and goals
(physically and emotionally) - Individualize the process on
and has privacy the basis of the health of the
- It is also essential for the patient and concerns that
nurse to develop trust and emerge during the course of
rapport at this point of the the interivew
interview (establish the name - “Sometimes how a patient
by which the patient prefers shares information is more
to be addressed, should be important than what the
patient says”

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 5.) Correlate data gathered during the
Asking open-ended questions interview and the physical
1.) Used when beginning interview to examination to form the foundation
elicit client concerns of a unique, patient-centered plan of
2.) Listen attentively to client care
3.) When client pauses; encourage
him/her to go on 4.) Termination Phase
4.) “Tell me more about it” - The nurse summarizes and
5.) Slightly lean forward and maintain validates information
eye contact obtained during the working
phase and validates
Asking closed or direct questions problems and goals with the
1.) Use after client’s open narrative to patient
fill in details that were left out - As the end of the interview
2.) Speeds up the interview approaches, care is taken to
3.) Ask one direct question at a time review key findings and
4.) Allow client to answer before asking prepare the patient for the
another question conclusion of the discussion
5.) Choose a language that client - The nurse also identifies and
understands discusses possible plans to
resolve problem (nursing
Health History diagnoses and collaborative
● Includes all information that can problems) with the patient
guide the development of a - The patient should be
patient-centered plan of care allowed to interject additional
(1) Reason for seeking health pertinent information
care - The nurse makes sure to ask
(2) History of current illness if anything else concerns the
(3) Allergies patient and if there are any
(4) Medications and adverse further questions. By
reactions reviewing the information
(5) Medical history with the patient, a consensus
(6) Family and social history is established
(7) Health promotion practices - Finally, the session is
concluded with the nurse
Review of Systems acknowledging the patient’s
1.) Collect subjective information participation and describing
2.) Ask brief questions about the normal the next steps that the
function of each body system patient should expect
3.) Ask more directive questions for any - Steps:
deviation and note later for the (1) Avoid abrupt and
physical assessment awkward closing
4.) Establish goals for care with patient
based on data gathered

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 (2) “Is there anything
Patient-Centered Nurse-Centered
else you would like to Approach Approach
mention?”
(3) “Our interview is just Involves nurse’s Involves nurse’s
about to be done” reactions to what own thoughts and
(4) State the summary of the patient has feelings
communicated
the interview
(5) Thank the person for Focuses on the Focuses on nurse’s
the time spent and for patient’s frame of frame of reference
their cooperation reference
(6) Explain the next steps
Patient leads the Nurse leads the
to expect after
conversation conversation
interview

Guidelines of an Effective Interview Patient-Centered Approach

● The interview will become part of a ● These skills must be utilized in
legal document patient communication
● Follow the 6 C’s: (1) Facilitation
(1) Client’s words in quotation - Use phrases to encourage
marks the client to continue
(2) Clarity - “Please go on, I’m with you”
(3) Concise (2) Silence
(4) Chronological - Keep silent for a second to
(5) Completeness have a chance to assess the
(6) Confidentiality client’s ability to organize his
● Guidelines: thoughts
(1) Address the client by name - Silent attentiveness
(2) Introduce yourself and your (3) Reflection
role - Echoes the person’s words
(3) Explain the purpose of the - Helps express the feeling
interview behind words and elaborate
(4) Tell the client how long the on the topic
interview will last (4) Empathy
(5) Reassure the client that the - Recognizes the feeling of the
data will be kept confidential client and puts it into words
(6) Formulate a general - It helps the clients feel
impression about client as a accepted and can deal with
whole (posture, speech, the feeling openly
signs of distress, facial (5) Clarification
expression, dressing, - To seek understanding when
grooming and hygiene) the client words are
ambiguous or confusing
Communication Skills During the Interview - “Tell me what you mean by
tired-blood”

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 (6) Confirmation mental slowness or confusion. If you
- Repeating what the person detect hearing loss, speak slowly,
says to correct a always face the client during the
misunderstanding interview, and position yourself so
that you are speaking on the side of
Nurse Centered Approach the patient that has the ear with
● These skills must NOT be utilized in better acuity
patient communication ● Older patients may have more
(1) Confrontation health concerns than younger
- Giving an honest feedback patients and may seek health care
about what you see or feel more often. Many times, they feel
(2) Interpretation vulnerable and scared. They need to
- Based on inference or believe that they can trust you
conclusion before they will share to you about
- Links events, makes what is bothering them.
associations and implies
cause Emotional Variations in Communication
(3) Explanation ● Not every patient you encounter will
- Informing the client by haring be calm, friendly, and eager to
factual and objective participate in the interview process
information ● Patients’ emotions vary for a number
(4) Summary of reasons. They may be scared or
- Final review of what you anxious about their health or about
understand the person has disclosing personal information,
said angry that they are sick, or about
having to have an examination,
Special Considerations During the Interview depressed about their health or
● There are three variations in other life events, or they may have
communication that can affect the an ulterior motive for having an
nonverbal and verbal techniques assessment performed
used during the interview: ● Patients may also have some
sensitive issues with which they are
Gerontologic Variations in Communication grappling and may turn to you for
● Age affects and commonly slows all help
body systems to varying degrees.
However, normal aspects of aging Ethnic/Cultural Variations in Communication
do not necessarily equate with a ● Reluctance to reveal personal
health problem, so it is important not information to strangers for various
to approach the assuming that there culturally-based reasons
is a health problem ● Variation in meaning conveyed by
● You must first assess their hearing language (barrier)
acuity. Hearing loss occurs normally ● Variation in use and meaning of
with age, and undetected hearing nonverbal communication: eye
loss is often misinterpreted as contact, stance, gestures,

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 demeanor. For example, direct eye ● 5 non-verbal cues that convey
contact may be perceived as rude, information about a person:
aggressive or immodest by some (1) Vocal cues
cultures but lack of eye contact may (2) Action cues
be perceived as evasive, insecure or (3) Object cues
inattentive by other cultures (4) Use of personal or territorial
● Variation in disease perception space
● Variation in the family’s role in the (5) Touch
decision making process ● Eye contact: most culturally variable
nonverbal behavior
Overcoming Language Barriers
1.) European Culture
Barriers to Effective Communication - Maintain eye contact when
● Stereotyping expectations on patient speaking
behavior 2.) Asian, American-Indian,
● Culturally diverse perceptions on Indochinese, Arab, Appalachian
role of health care provider - Direct eye contact is impolite
● Sick-role behavior in different and aggressive
cultures: 3.) American Indians
(1) American-Jewish and - Staring at the floor means
Italians: complaining and paying attention
demanding 4.) Hispanics
(2) American-Indians & Asians: - Downcast eyes towards
quiet and compliant others
(3) Appalachians: hesitant to 5.) Muslim-Arab
answer questions, reject - Avoiding eye contact with
interviewer men indicates modesy

Working with (and without) an Interpreter ● Touch: necessary component of a

● When interviewing non-English comprehensive assessment and
speaking client, always get a trained may convey various meanings
medical interpreter only and cross-culturally
non-verbal cross-cultural 1.) Arab and Latino Cultures
communication - Male Health care
● Talk to the patient directly and not professional (HCP) may be
the interpreter prohibited from touching a
● Allow for time for the interview to female client
finish - Mal-ojo
● Types of Interpreting: 2.) Asians
(1) Line-by-line interpreting - Touching the head is
(2) summarizing disrespectful
3.) Southern Asia
Non-Verbal Cross-Cultural Communication

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- Touching an infant’s fontanel
should be done only with
parental consent

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