Interview and Nursing Assessment Skills - NURS 3410
Clinical Judgment Measurement Model and Critical Thinking
The Clinical Judgment Measurement Model, copyrighted by NCSBN, serves as the primary framework for clinical decision-making. This cyclical process begins with Assessment, where the nurse focuses on the phase of Recognize cues. This leads to Diagnosis, which involves the phases of Analyze cues and Prioritize hypotheses. The sequence continues into Planning, characterized by the phase to Generate solutions, followed by Implementation, where the nurse must Take action. Finally, the cycle concludes with Evaluation, where the nurse must Evaluate outcomes.
Critical thinking within the assessment of clients is influenced by five major components: Knowledge Base, Experience, Standards, Attitudes, and Environment. The Knowledge Base encompasses basic sciences such as anatomy, physiology, and microbiology, as well as nursing theories supporting health and wellness, communication principles, and family dynamics. Experience includes personal and clinical experience in assessment and physical examination. Standards involve the ANA Standards and Scope of Nursing Practice, clinical practice guidelines, agency policies, and ethical standards. Attitudes required for excellence include perseverance, curiosity, confidence, discipline, and responsibility. The Environment refers to external factors such as time pressure, setting, task complexity, and interruptions.
Sources of Data and Types of Assessments
There are several key sources for data collection in nursing. The best source of information is the Client through interview, observation, and physical examination. Other sources include the family and significant others (though the nurse must obtain the client’s agreement first), the health care team, medical records, and scientific literature.
Primary types of assessments include the client-centered interview conducted during a nursing health history, the physical examination, and periodic assessments performed during rounding or while administering care. Assessment involves identifying cues, which are divided into subjective and objective categories. Subjective Client Cues consist of the client’s verbal descriptions of their health problems, feelings, perceptions, self-reported problems, and reports from the family or during handoff. Objective Client Cues are observations or measurements of the client's health status, including the physical assessment, information in the medical record (EHR), and laboratory test results.
In a clinical scenario where a nurse, Yolanda, enters Ms. Thompkins’ room to begin an admission health history and the client complains of pain at the incision site, this is classified as a subjective cue because it is the client's verbal description of their sensation.
The Nurse-Client Relationship and Interview Techniques
Effective communication is the foundation for creating nurse-client relationships and is essential for trust building, presence, and rounding. The interview process itself is divided into three distinct phases: orientation, working, and termination. During the interview, two main types of questions are utilized. Open-ended questions are used to elicit narrative responses and are most effective to begin an interview, introduce a new set of questions, or when the client introduces a new topic. Closed-ended questions require only one or two words, such as "yes," "no," "right," or "left."
Observation of client behavior is a critical skill, encompassing both verbal and nonverbal behaviors. These observations direct the nurse to gather additional objective information to form accurate conclusions about the condition. Observation also includes assessing the client’s level of function, which covers physical, developmental, psychological, and social aspects of everyday living. Cultural considerations are also paramount; cultural competence involves self-awareness, reflective practice, and knowledge of a client's core cultural background, while cultural humility requires the nurse to recognize their own knowledge limitations and remain open to new perspectives.
Comprehensive Nursing Health History Components
A nursing health history is a key component of a comprehensive assessment and covers multiple dimensions. The Physical and Developmental dimension includes perception of health status, past health problems/therapies, risk factors, growth, and ADLs (Activities of Daily Living). The Intellectual dimension covers intellectual performance, problem solving, educational level, and communication patterns. The Emotional dimension includes behavioral status, support systems, self-concept, body image, and coping mechanisms. The Social dimension focuses on financial status, primary language, cultural heritage, and environmental risk factors. The Spiritual dimension involves beliefs, religious rituals, and fellowship.
Biographical data collected includes Name, Address, Phone number, Age, Birth date, Birthplace, Sex, Marital status, Race, Ethnic origin, and Occupation (both usual and present). When recording the Reason for Seeking Care, the nurse should use a brief statement in the person’s own words, placing the client's exact words in quotations. A Symptom is defined as a subjective sensation the person feels, while a Cue (formerly sign) is an objective abnormality detectable on physical exam or in labs.
Analyzing Symptoms and Past Health History
To analyze present illness or health concerns, nurses use the PQRST or OLDCARTS mnemonics. PQRST stands for Provokes (what causes the pain), Quality (what it feels like), Radiate (where it is located), Severity (rating on a scale of to ), and Time (timing/duration). OLDCARTS stands for Onset, Location, Duration, Characteristics, Aggravating factors, Alleviating factors, Timing, and Setting.
Past Health History includes hospitalizations, injuries, surgeries, medications, allergies, blood transfusions, habits (alcohol, tobacco, caffeine, or recreational drug use), and patterns of coping, sleep, exercise, and nutrition. Family History identifies the age and health/cause of death of relatives and tracks conditions such as high blood pressure, stroke, diabetes, cancer, sickle-cell anemia, arthritis, and kidney disease.
Genograms and Family Tree Construction
A genogram or family tree is used to show family history clearly. In a genogram, a square represents a male and a circle represents a female. A diagonal line through a square or circle indicates the person has died. Parents who are divorced or not together are indicated by a specific line. Pregnancy loss is documented with the number of weeks, and "SB" stands for stillbirth. Siblings and parents' siblings are drawn from oldest to youngest, left to right. If sex and number of children are known, they are indicated individually; if only the total number is known, a diamond with the number inside is used (e.g., a diamond with means eight children of unknown sex).
Review of Systems and Specialized Assessments
The Review of Systems (ROS) is a systematic examination of all body systems, including the General health state, Skin, Hair, Head, Eyes, Ears, Nose/sinuses, Mouth/throat, Neck, Breast, Axilla, Respiratory, Cardiovascular, Peripheral vascular, Gastrointestinal, Urinary, Genital (Male/Female), Musculoskeletal, Neurologic, Hematologic, and Endocrine systems.
For Older Adults, a Functional Assessment is required to measure self-care ability. This includes evaluates ADLs, self-concept, occupation, activity/exercise, sleep, nutrition/elimination, interpersonal relationships, coping, and home safety hazards. Documentation of all assessment data must use clear, concise terminology to become the baseline for care. Concept mapping may be used as a visual representation to cluster cues and show connections among health problems, leading to the nursing diagnosis.
Questions and Discussion
Question: A patient expresses fear of going home and being alone. Vital signs are stable, and the incision is nearly completely healed. What can the nurse infer from the subjective data? Answer: c) The patient is fearful of being discharged. This is the direct inference from the patient's verbal expression of fear regarding returning home alone.
Question: The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? Answer: a) The patient’s room with the door closed. Rationale: This environment minimizes background noise and distractions, which is essential for a patient with a hearing deficit.
Question: Matching PQRST components: 1. What causes the pain? - e. Provokes. 2. What does the pain feel like? - 7. Quality. 3. Where is the pain located? - c. Radiate. 4. What is the rating on a scale to ? - d. Severity. 5. Does it come and go? - 6. Time.
Question: For which of the following patients can the nurse safely delegate morning care to an experienced unlicensed assistive personnel (UAP)? Patients include: 1. 32-year-old with closed head injury; 2. 76-year-old with septic shock; 3. 62-year-old post-op bowel obstruction (day 2); 4. 23-year-old with asthma exacerbation/dyspnea. Answer: 3. The 62-year-old patient who underwent surgery 2 days ago. Rationale: This patient is stable. Patients with closed head injuries, septic shock, or acute asthma exacerbations are unstable and require the critical thinking of an RN to detect respiratory compromise or other changes in condition.