Class notes:

Adult Health Assessment – Interview and General Survey The Assessment

Assessing: the systematic and continuous collection, validation and communication of patient data.
A database includes all pertinent patient information collected by the nurse and other health care
professionals.
The collection of patient data is a vital step in the nursing process because the remaining steps depend
on complete, accurate, factual, and relevant data.
Goal: to establish a trusting and supportive relationship, to gather information and to offer
information.
THE TECHNIQUES OF SKILLED INTERVIEWING
Active listening: the process of fully attending to what the patient is communicating, being aware of
the pt.’ s emotional state and using verbal and non verbal skills to encourage the pt. to continue
speaking. CONCENTRATE.
Adaptive questioning:
Direct questioning: from general to specific.
Questions to elicit a graded response: how many steps can you climb before you get SOB vs. what
physical activity do you do that makes you SOB?
Ask a series of questions one at a time.
Offering multiple choices for answers: Is your pain sharp, stabbing, sharp or what?
Clarify what the patient means: You say your pain is in the stomach?
Nonverbal Communication: pay close attention to eye contact, facial _expression, posture, head
positioning and movement. Match your position with the patient. Use therapeutic touch.
Facilitation: by using silence, pause, a nob of the head.
Echoing: repeating words of the patient for the sake of clarification.
Empathic responses: I understand, it must be difficult, that sounds upsetting.
Validation: It must have been scary to be in the car accident.
Reassurance: identify and accept the patient’ s feelings. Avoid saying, don’ t worry, things will be okay.
Summarization: summarize what your patient has said.
ADAPTING INTERVIEW TECHNIQUES TO SPECIFIC SITUATIONS
The silent patient: watch the patient closely for non-verbal cues (difficulty controlling emotions, facial
_expression, rubbing or moving hands). You seem very quiet, have I done something to upset you? If the
patient is laconic, ask permission to interview a family member.
The talkative patient: Give patient first 5-10 min and listen closely. Are their flights of idea or
disorganized thoughts? Interrupt courteously if necessary. Set limits and focus the conversation on
specific subjects (pain). Set time limit.
The anxious patient: Set limits (time), be empathetic, encourage relaxation exercises (deep
breathing).
The crying patient: Pause, encourage crying, be empathetic. Offer tissue and make a supportive
comment, I am glad you got that out.
The angry or disruptive patient: accept angry _expression without getting angry yourself, most likely
there anger may be a displacement of their own suffering. Acknowledge the patient’ s feelings.
The patient with a language barrier: use an interpreter.
The patient is reading problems: assess the patient reading ability courteously.
Patients with impaired hearing: Use sign language interpreter when needed, use written questions
when needed, however it may be time consuming. If patient can read lips, face them directly, in good
light, speak slowly, do not cover your mouth, and do not chew gum.
Patient with impaired vision: shake hands, establish contact and explain who you are. Describe the
environment and mention is someone else is in the room.
The poor historian: use a third party.
Special aspects of interviewing (sensitive topics)
Cultural competence: consider the patient’ s culture when performing an assessment. Work on your
own biases, eliminate assumptions about what is normal, and build a respectful relationship with your
client.
Alcohol and drug history: ask what alcohol is, how much they drink and how often.
The sexual history:
Domestic and physical violence: be aware of unexplained injuries, if the patient has delayed getting
treatment for trauma, if there is a past history of accidents or injuries. If you suspect abuse, speak to
the patient alone.
The mental health history: use open-ended questions: have you ever had any problems with emotional
or mental illness, then, have you ever seen a psychotherapist or psychiatrist?
INTERVIEWING PATIENTS OF DIFFERENT AGES
Talking with children: interview both the child and parent. Establish rapport; introduce yourself to
both parties, clarify the role or relationship of the adult and child. Maintain eye contact with child, sit
on the floor if necessary, and explain in simple terms.
Talking with Adolescents: introduce yourself, begin interview by asking questions about school, friends,
hobbies and family. Avoid using silence with adolescents. Reassure and provide confidentiality as long
as the patient’ s safety is at risk. Ask parents to step out of the room; obtain past history from parents.
Talking with aging patient: give pt. time to respond, speak slowly and clearly, provide a comfortable
room free from distraction.
General Survey and Vital Signs
Observation: observe the patient’ s mood, built and behavior. Does the pt. rise
with ease, hear you, and walks easily or stiffly? Apparent state of health (frail), LOC, any signs of
distress (pain, respiratory), height and build, weight, skin color or lesions, dress, grooming and
personal hygiene, facial expression, odors, posture and gait.
Vital Signs
Blood Pressure: obtain appropriate cuff size. Consider the following when taking BP:
Anxiety/nervousness may affect BP. Obese or thin patient, use appropriate cuff size. Weak or inaudible
Kortokoff sounds, arrhythmias. Normal blood pressure should be 120/80, baseline assessment is
important.
Heart rate and rhythm: heart rate should be assessed in the radial site. If rhythm is irregular, assess
rate in the apical site. Rhythm: should be regular, if not check the apical site (cardiac apex). Normal
rate should be 60-100. Take into account patient’ s age and physical condition.
Respiratory rate and rhythm: Assess rate, rhythm, depth, and effort. Count for I minute, normal ranges
14-20 bpm.
Temp. : Normal 98.6; in the mornings the temp may be as low as 96.4 and in the evenings it may be as
high as 99.1. Rectal temp. are higher than oral by 0.7-0.9 degrees F. Axillary’ s temp. are lower than
oral by approximately 1 degree, but takes 5-10 minutes to register. Do not use oral thermometer on
patients that are unconscious, restless or agitated. Wait 10-15 min. if patient had something hot or
cold in their mouth.