NR509
Week 1 Foundations of Advanced Assessment
Client Assessments
Subjective Data versus Objective Data
oExamples of Subjective Data
Lower back pain
Fatigue
Stomach cramps
Immunization history
oExamples of Objective Data
Heart rate
Blood pressure
Lung sounds
Wound appearance
Ambulation description
Weight NR509
Basic Interviewing Techniques
Active Listening: Active listening involves closely attending to what the client is communicating, connecting to the client's emotional state, and using verbal and nonverbal skills to encourage the client to expand on their feelings and concerns.
Empathy: Empathy encompasses identifying with the client and feeling their pain as one’s own, then responding to them in a supportive manner.
Guided Questioning: Guided questions help to elicit more information, while still showing a continued interest in the client’s feelings and story. Some techniques of guided questioning include moving from open-ended to more focused questions; clarifying what the client means; encouraging with continuers such as “go on”; using a series of questions one at a time; and using questions that require a graded response (i.e., how many stairs can you climb before feeling short
of breath?).
Nonverbal Communication: Nonverbal communication includes eye contact, facial expression,
posture, head position, and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs (i.e., crossed, neutral, or open).
Validating: Validation is affirming the legitimacy of the client's emotional experience. Examples include: “That must have been a difficult experience. It’s very common to feel the way
you are feeling.” “You doing a great job keep doing what you”
Reassuring: Reassurance is an appropriate way to help the client feel that problems have been fully understood and are being addressed. ( Example there are resources out there and we are here to help)
Partnering: Partnering involves expressing commitment to an ongoing relationship with the clients to build rapport.
Summarizing: Giving a summary of the client's story during the interview helps to communicate that they have been carefully listening to.
Transitioning: Transitions can be used to inform the client that the direction of the interview is changing.
Empowerment: Empowering clients to ask questions and express their concerns increases the chances that they will adopt your advice, make lifestyle changes, or take medications as prescribed. Build the patient up to continue to make changes ( for example sticking to their diet)
Examples Statements of Interviewing Techniques Empathy: “I understand this has been difficult for you. Let’s talk about what we can do to help this situation.”
Guided questioning: “Tell me about your abdominal pain. Where else do you feel it? What makes it worse?” NR509
Validation: “That must have been very scary. It is normal to feel this way after an event like that.”
Partnering: “Thank you for sharing about your anxiety. I think we can come up with a plan together to help you feel better.”
Transitions: “Now I would like to ask you some questions about your previous health.”
Summarization: “You have told me a lot of things. Let me restate what you have shared so you can verify that I have heard you correctly.”
Comprehensive Health History:
1.Chief Complaint: The chief complaint is the primary problem that prompted the client to schedule a visit with the provider and is a starting point to begin information gathering. When documenting the chief complaint, attempt to use the client’s own words. For a client who presents with multiple complaints, it is important to determine if a relationship exists between the symptoms and if there is a primary problem with accompanying symptoms. If the client reports no specific complaints, report the reason for their visit such as “I am here for a regular check-up.”
2.History of Present Illness : The history of the present illness is a concise, clear, and chronological description of the chief complaint which prompted the client’s visit. A symptom analysis guided by the mnemonic OLD CARTS will reveal information regarding the onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and severity of the symptoms. There are other mnemonics and variations of OLD CARTS that may also be used to guide in gathering information about the chief complaint.
oD o c u m e n t a t i o n o f H i s t o r y o f P r e s e n t I l l n e s s : The history of present illness documentation should include an opening statement, a characterization of the chief complaint in chronological order, pertinent positive symptoms, pertinent negative symptoms, and other relevant information from the history. Pertinent positives are symptoms that are expected with a potential diagnosis related to the chief complaint. Pertinent negatives are symptoms the client
does not have that are expected with a potential diagnosis related to the chief complaint.
Example: Chief Complaint: Abdominal Pain
History of Present Illness: Mrs. Smith is a 48-year-old female with a two-week history of progressive, intermittent right upper quadrant pain rated 3 to 4 out of 10, with occasional radiation to the right shoulder. The pain is described as a crampy, gnawing ache not relieved by antacids or NSAIDs. She reports associated anorexia, nausea, and vomiting (nonbilious, non-bloody) for the past two days. The pain was initially provoked by eating fatty fast food. Over the last two days, any/all ingestion has resulted in pain and vomiting, and she has been unable to go to work. Further review is significant for subjective fevers, without chills, rigors, or night sweats; she
denies diarrhea, constipation, melena, or hematochezia. However, her stools have
Week 1 Foundations of Advanced Assessment
Client Assessments
Subjective Data versus Objective Data
oExamples of Subjective Data
Lower back pain
Fatigue
Stomach cramps
Immunization history
oExamples of Objective Data
Heart rate
Blood pressure
Lung sounds
Wound appearance
Ambulation description
Weight NR509
Basic Interviewing Techniques
Active Listening: Active listening involves closely attending to what the client is communicating, connecting to the client's emotional state, and using verbal and nonverbal skills to encourage the client to expand on their feelings and concerns.
Empathy: Empathy encompasses identifying with the client and feeling their pain as one’s own, then responding to them in a supportive manner.
Guided Questioning: Guided questions help to elicit more information, while still showing a continued interest in the client’s feelings and story. Some techniques of guided questioning include moving from open-ended to more focused questions; clarifying what the client means; encouraging with continuers such as “go on”; using a series of questions one at a time; and using questions that require a graded response (i.e., how many stairs can you climb before feeling short
of breath?).
Nonverbal Communication: Nonverbal communication includes eye contact, facial expression,
posture, head position, and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs (i.e., crossed, neutral, or open).
Validating: Validation is affirming the legitimacy of the client's emotional experience. Examples include: “That must have been a difficult experience. It’s very common to feel the way
you are feeling.” “You doing a great job keep doing what you”
Reassuring: Reassurance is an appropriate way to help the client feel that problems have been fully understood and are being addressed. ( Example there are resources out there and we are here to help)
Partnering: Partnering involves expressing commitment to an ongoing relationship with the clients to build rapport.
Summarizing: Giving a summary of the client's story during the interview helps to communicate that they have been carefully listening to.
Transitioning: Transitions can be used to inform the client that the direction of the interview is changing.
Empowerment: Empowering clients to ask questions and express their concerns increases the chances that they will adopt your advice, make lifestyle changes, or take medications as prescribed. Build the patient up to continue to make changes ( for example sticking to their diet)
Examples Statements of Interviewing Techniques Empathy: “I understand this has been difficult for you. Let’s talk about what we can do to help this situation.”
Guided questioning: “Tell me about your abdominal pain. Where else do you feel it? What makes it worse?” NR509
Validation: “That must have been very scary. It is normal to feel this way after an event like that.”
Partnering: “Thank you for sharing about your anxiety. I think we can come up with a plan together to help you feel better.”
Transitions: “Now I would like to ask you some questions about your previous health.”
Summarization: “You have told me a lot of things. Let me restate what you have shared so you can verify that I have heard you correctly.”
Comprehensive Health History:
1.Chief Complaint: The chief complaint is the primary problem that prompted the client to schedule a visit with the provider and is a starting point to begin information gathering. When documenting the chief complaint, attempt to use the client’s own words. For a client who presents with multiple complaints, it is important to determine if a relationship exists between the symptoms and if there is a primary problem with accompanying symptoms. If the client reports no specific complaints, report the reason for their visit such as “I am here for a regular check-up.”
2.History of Present Illness : The history of the present illness is a concise, clear, and chronological description of the chief complaint which prompted the client’s visit. A symptom analysis guided by the mnemonic OLD CARTS will reveal information regarding the onset, location, duration, characteristics, aggravating factors, relieving factors, treatments, and severity of the symptoms. There are other mnemonics and variations of OLD CARTS that may also be used to guide in gathering information about the chief complaint.
oD o c u m e n t a t i o n o f H i s t o r y o f P r e s e n t I l l n e s s : The history of present illness documentation should include an opening statement, a characterization of the chief complaint in chronological order, pertinent positive symptoms, pertinent negative symptoms, and other relevant information from the history. Pertinent positives are symptoms that are expected with a potential diagnosis related to the chief complaint. Pertinent negatives are symptoms the client
does not have that are expected with a potential diagnosis related to the chief complaint.
Example: Chief Complaint: Abdominal Pain
History of Present Illness: Mrs. Smith is a 48-year-old female with a two-week history of progressive, intermittent right upper quadrant pain rated 3 to 4 out of 10, with occasional radiation to the right shoulder. The pain is described as a crampy, gnawing ache not relieved by antacids or NSAIDs. She reports associated anorexia, nausea, and vomiting (nonbilious, non-bloody) for the past two days. The pain was initially provoked by eating fatty fast food. Over the last two days, any/all ingestion has resulted in pain and vomiting, and she has been unable to go to work. Further review is significant for subjective fevers, without chills, rigors, or night sweats; she
denies diarrhea, constipation, melena, or hematochezia. However, her stools have
