A patient-centered interview is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness (Smith et al., 2006). The interview technique is the basis of a conceptual model used by nurse practitioners to form long-term therapeutic relationships with patients (Lein and Wills, 2007). However, the model has aspects that are useful to all nurses when conducting interviews for patient assessment. The partnership that forms in a patient-centered interview empowers a patient, promotes mutual decision making with the nurse, and ensures continuity of care (Dontje et al., 2004). Show
The expectation in a busy acute care setting such as a hospital nursing unit or clinic is for nurses to complete in a limited amount of time a patient history and nursing assessment. In the home health setting there is usually more time and fewer distractions; this allows a nurse to conduct a thorough interview. Agencies set standards for the type of information to be collected in health histories. However, there is a risk that standard assessments do not capture the patient’s full story. In a patient-centered interview an organized conversation with the patient allows the patient to set the initial focus and initiate discussion about his or her chief problems or reasons for seeking health care (Lein and Wills, 2007). A successful interview requires preparation. Collect available information about the patient before starting the interview. For example, review the information you learn during a change-of-shift report and then plan to interview the hospitalized patient as you make patient rounds and before you begin to provide ordered interventions. Create a favorable environment for the interview. A good interview environment is free of distractions, unnecessary noise, and interruptions. The patient is more likely to be open and honest if the interview is private (i.e., out of earshot of other patients, visitors, or staff). Timing is important in avoiding interruptions. If possible, set aside a 10- to 15-minute period when no other activities are planned. More time is even better but is difficult to plan when you have multiple patients. During the interview always observe your patient for signs of discomfort or fatigue and plan accordingly. Remember to let a patient decide whether to involve the family in the interview. After an initial interview, follow-up discussions allow you to learn more about a patient’s situation and focus on specific problem areas. An initial patient-centered interview involves: (1) setting the stage, (2) gathering information about the patient’s chief concerns or problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview. Collect the Assessment or Nursing Health HistoryStart an assessment or a health history with open-ended questions that allow patients to describe more clearly their concerns and problems. For example, you can begin by having the patient explain symptoms or physical concerns, describe what he or she knows about the health problem, or ask him or her to describe health care expectations. Use attentive listening and other therapeutic communication techniques (see Chapter 24) that encourage a patient to tell his or her story. Observe verbal cues the patient expresses. Stay focused and orderly and do not rush. An initial interview (e.g., the one you conduct to collect a complete nursing history) is more extensive. You gather information about the patient’s concerns and then complete all relevant sections of the nursing history (see the following dialogue). Ongoing interviews, which occur each time you interact with your patient, do not need to be as extensive. An ongoing interview allows you to update the patient’s status and concerns, focus on changes previously identified, and review new problems. In the case study Tonya is gathering information to plan her postoperative teaching for Mr. Jacobs. Tonya: “Mr. Jacobs, tell me what you expect over the next few days before you go home.” Mr. Jacobs: “Well, the doctor did tell me that I would have this catheter in my bladder after I go home. But I don’t know if I have to do anything with this dressing over my stitches.” Tonya: “Un huh, go on.” Mr. Jacobs: “Will I have something to take for this pain as long as I am here, and what will I have to take at home?” Tonya: “Yes, your doctor has ordered your pain medicine every 4 hours around the clock. You need to tell us when you begin to feel uncomfortable. You’ll have a pain medicine prescribed when you go home. Do you have any other concerns or questions about your surgery?” Mr. Jacobs: “No, I don’t think so.” Tonya: “Ok. First you’re right; the catheter will stay in your bladder, probably about 2 weeks. Your surgeon will have you come to the office to have it removed. We’ll talk about how you and your wife can manage the catheter, and we’ll probably recommend a visit by a home health nurse. I want to look at the dressing over your incision more closely. You have a small drain in the incision to make sure fluid drains and the tissues heal well. I want to talk with you and your wife about how to observe for signs of infection.” Mr. Jacobs: “Is infection common?” Tonya: “No, but you need to know the signs of an infection; so, if something happens once you return home, you can call your doctor quickly.” Which primary source of information would the nurse use when completing a patient's assessment quizlet?The client is the primary, and usually best, source of information when doing an assessment. The medical record may also provide information, but only if the client has been at the health care facility before; even then, the client is likely to have more current information than the medical record.
What is your primary source of information when obtaining a patient history?Primary sources of information are attained from the patient themselves (i.e., physical assessment and patient report of symptoms). Secondary sources include family members and the health record.
What are possible sources of information to use in the assessment step of the nursing process quizlet?Identify four sources of assessment data. The primary source of information is the client (physical assessment and interview). Secondary sources include the client's family, reports, test results, information in current and past medical records, and discussions with other health care providers.
What is the nurse's primary source for data collection?What is the nurse's primary source for data collection? The nurse's primary source of data is the patient; however, there may be times when it is necessary to supplement or rely completely on another for the assessment information.
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Which primary source of information would the nurse use when completing a patients assessment?
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