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Assessment procedures : Assessment interview

When you first meet with the patient, introduce yourself and the address of her relationship, using his proper title. This gives him the opportunity to choose what they want to play during their stay. If he is patient, other patients to report to him in his room and show her around the clinic, so he knows where the toilet and bathtub or shower rooms, and where to find the phone, or day room. Often, the patient's first experience of health care and can not be nervous. It is worth taking the time to explain and make him feel that he is a multi-disciplinary care, and how to distinguish the different uniforms, it is likely to meet with staff. If English is not their first language, you may find that there is a language barrier, so before you proceed for an interview, if you can find a translator.

Tip: If a patient needs an interpreter to family members want to order, but some private information about a patient may not be suitable for family members, especially children, to interpret. For example, a woman can not find it easy to talk about abuse within the family, his son is a translator, it may be appropriate to use the official interpreter.

Preparing for an interview

Before interviewing the patient, it is important to prepare for the interview and the assessment of the patient. Explain that you will need to gather some information and that it is a convenient time to interview him. For example, a patient can go to the bathroom, to change his position because of pain, or say goodbye to relatives first. You need to collect the key personal medical records, so you can check the details of such information as date of birth, address and telecommunications numbers of relatives.

Could it be useful to include the relative Tip: If you look at some of the details of a major career in an interview with them or separately. However, the patient is aware that all information that it gives you the information to be kept confidential and only, other health professionals if necessary. In some cases, it may be particularly important for both the caregiver and the patient is able to express real anxiety, and other discussions. This should be considered sensitive and must take place in the preliminary assessment.

Interview with the atmosphere

To provide a comfortable and peaceful place to interview, if possible, and that you are not so close to the patient that you invade her personal space, but not so far away that you do not need to shout. Make sure that the patient can see and that you are placed in the light behind him. Try to calm, slow and non-judgmental atmosphere. By giving the patient time and attention, he is more likely to relax and open, and provide all the necessary information. If you show your disapproval, disgust, impatience, or it may inhibit communication (Bates and Hoekelman 2000), so you need to develop their professional behavior that does not make the patient feel guilty about, or vulnerable to some of your lifestyle - such as alcohol or tobacco consumption.

Effective communication

Keep in mind that some of the medical jargon may prevent the patient's understanding of the questions asked to use layman's language and terminology. Encourage the patient, as he says, nodding the head, and say things like "Go". Help him to tell his story, asking questions such as "Can you tell me where the problem started?".

Non-verbal communication can also tell the person. Listen carefully and watch the body language signals. If a person is uncomfortable half the questions, it does not make eye contact. In some cultures, however, can be regarded as disrespectful to the eye, or aggressive and may not meet your eyes at all during the interview (Spring House 2002). It is important to check that you understand the signals correctly. For example, if the patient is to keep the pain itself, for example, you might ask, "You look very uncomfortable right now, can you tell me how you feel?" It provides an opportunity to talk about all the pain, he may be feeling, or concerns they may have. Outbursts of anger, aggression, arrogance, or the tears of this type of non-verbal behaviors that communicate emotions such as anxiety, insecurity and fear.

their story so many tips! Some patients say they are bound by a finding that it actually impoverishes them to take up important things first, especially in emergency admissions. You can fill the gaps in any of the following medical records, letters, other health professionals, primary care staff in communications, emergency medical records, or with friends and relatives.

There are a variety of communication skills, you can use when interviewing. Closed questions used to get one or two word answers, and to establish specific categories of information such as address information. Open-ended questions give the opportunity to express their feelings and thoughts, and to share their experiences of the patient. Hoekelman and Bates (2000) to identify other communication strategies used to present information on:


This encourages the patient to continue his story. You can use the position of attention, such as nodding or leaning forward and listening to the silence, the patient collects his thoughts.


Playing in the patient's back to the words he just said, can help him to collect his thoughts, and to develop further.


It makes you so sure of the exact number of tracks and clear the misunderstandings.


Іf thе patient is a bit vague, unclear, or you can ask him to explain in more detail.

Ask your emotions:

You can ask the patient what he thought about the situation or event, because it can give him to articulate anxiety, anger or fear.


This is another information that is certain to you to do this mutually.


This indicates the end of the interview, but it offers the patient the opportunity to say something, it can be added.

Structural Assessment Interview

Hoekelman and Bates (2000) Evaluation of an interview with an overview of the structure, including the following:

• Personal Information
• Whether the admission
° A History
• Family History
° the ability to do everyday activities
• All the psychosocial factors that may affect the health of
° A physical assessment of vital signs.

In addition, more detailed assessment can be carried out some specific features of the daily diet, breathing, restraint, or other specific areas, depending on the patient's needs and problems.

Recording the information

Most of the evaluation forms are certain areas that have been made in writing and the same structure as the selected model for nursing.

Without the experience can be very dependent on paper and you can be the next question, and not be able to view the patient tips his true feelings. You may be beneficial for some notepaper, you can take some important points, which can then be recorded clearly in the right order, so the local documents. Be sure to explain to the patient, you want to save the data accurately. Write down the key phrases and dates, not the whole story, especially when complex issues are dealt with. There may be some moments of the interview, if there is reason to listen to, rather than writing, especially if the person is speaking, or sensitive to embarrassing questions.


First of all, check the bibliographic information. This should include the patient's full name, address, telephone number, age, date of birth, marital status and religion. Contact the number of people who can be included in an emergency and it could be a close relative or, if they live farther away, a partner or spouse. It is common for that who could be contacted during the night, especially if a partner or spouse is elderly and ill. Patients may be concerned about the implications for someone to call in an emergency, so it makes sense to clarify that it is important to ensure that all emergency contact information up to date and the number of rarely needed.

Enquirie the patient the opportunity to practice his religion, he claimed to express whether they want to monitor in particular religious traditions, such as by participating in the service of particular times or saying prayers. There may be cultural practices, in particular, that he would like to monitor the condition of time and should be available so as you can. For more information about cultural awareness may be advisable to monitor the processing of texts.

September admission

Use the patient's own words to explain in detail in September to access treatment. Framework for the use of PQRST to monitor a lot more (Spring House, 2002), in order to direct questions:

P - palliative or provocative. What help or aggravate the symptoms? There are certain situations such as stress or specifically state change?

Q - quality or quantity. What is a symptom of view, feel or sound like? Does he feel it during the interview? How does that affect his daily life?

R - regions or radiation therapy. If a symptom does not occur in the body? Is there anywhere else in the work?

S - severity. How serious is it a symptom of range of 1-10 (10 is the worst)? Does it get better, worse or staying the same?

T - time. When does it start? Does it begin gradually or suddenly? If you happen on a regular basis? How long will it last?


UK Medical information stored in these key states, but it is important that nurses, in order to determine whether allergies, elastoplast, perfume or other substances. Previous activities and accomplishments are together, so that it is understandable that when the last event is suitable for the patient's health status and experience of how it may impair the response to current treatment.

Find out the current treatment: whether prescribed by a doctor, pharmacist, or advised the patient self-dosing. For example, this may mean some inconvenience to the patient occurred when the pain has not been effective and the patient is over the counter medications by supplementing it without realizing the effect of increasing dose.

Family history of

It is not unusual to find no medical conditions such as heart disease, certain types of cancer or blood disorders, high blood pressure or diabetes are common in the family.

Ability to perform daily living activities,

This part of the evaluation is to establish whether areas that require focused evaluation. Nursing models outlined in Pearson et al. (1996) can be used to identify deficiencies in activities of daily living skills. Accurate account of the following areas.


Was it taking effect on appetite? Will he be able to shop and cook? Are there any special diet, such as diabetes or religious preferences?

The patient is such that the tip! Make sure areable I want to meet special diets, and, as noted. If it requires a kosher or vegetarian dishes to make sure it is ordered, or it can make the "extra" food that does not meet your needs.


What are the patient's normal elimination patterns, and they have recently changed? If constipation is a problem, which is the usual measures to alleviate the patient to use it? Is urinary incontinence, or a problem?


This includes all body movement: walking, moving bed, and manual dexterity. The amount of subsidy is required to keep the patient should be considered mobile, and special equipment may be necessary. For example, when the movement of the assessment, you may decide that the patient is not sufficient to support the monkey moving bed, or walking to support the toilet. It may be desirable to provide a better assessment of the patient physiotherapist. If the patient does not move and they may be at risk of complications of bed rest.


This consideration should be given to see, hear, smell, touch and taste. It is worth considering whether the patient is hearing impaired, which require a hearing aid, or if he or she has read lips or use sign language. Vision problems are the need to wear glasses, and if so what kind: short or long sight, the existence of glaucoma or tunnel vision. Patients with definite neurological disorders can detect the odor or taste senses are provisionally or enduringly changed.


The patient may have had their sleep disturbed, and the remainder of his current problems, so it is important to know the normal sleep cycle. It may be a special evening rituals, such as a hot drink or drugs or alcohol before bedtime. His sleep may be disturbed because of urination, or because he does not expect, especially in a situation in which to sleep in the BEC. of his illness. For example, if he has a soul, he might not be able to lie down comfortably, but feels that it sat in sleep disorders.


The patient may be affected by the current professional problem, and may be a factor, even though he is no longer gainfully employed. The work may cause the patient to recover from an illness or to help their rehabilitation. If a person is unemployed or is terminated, the impact on its financial position, and quite possibly his mental health. Individual disease can also affect what kind of work they will be able to continue, so that this information may be relevant in preparing the budget. Tobacco, alcohol and other drugs to find out how many cigarettes or how much tobacco smoke, or if he has given up. Amount of alcohol, the patient typically uses it is also important, and if you are able to ask him if he uses illegal drugs or the presence of a minor, this information is helpful as well. For example, a patient may be suffering from multiple sclerosis and cannabis for pain may be quite willing to admit to regular use. However, a person involved in an accident may be less open to drugs or alcohol. Conventional therapy - such as birth control pills or hormone replacement therapy - is also registered.

role to play tricks! BEC. You are the alcohol health worker, a patient may want to be honest, how much alcohol, tobacco, or drugs they consume, especially if he thinks the problem may be with them, or if he feels you are likely to be judgmental. Do not suggest he should start smoking cessation programs at a time just trying to get an honest assessment of how much he smokes a day. For example, instead of saying, "Do you smoke one or two packs a day?" Ask him how many packs a long time, and when they purchase, which will take him.

Psychosocial factors that may affect the health of

Professional patient information is already given an indication of the financial position. Ask the property: if it is rented or owned by the patient, or if it has central heating, or a lot of stairs, it gives a hint quality of accommodation. If the patient is that he can not do a lot of the BEC. Elevator rarely works that may affect the design is cleared, mainly in its ability to shop or cook.

Recent experience of grief, such as divorce, separation or bereavement can affect the patient's mood and the usual coping mechanisms. If you find yourself during the interview, when the patient has experienced in recent grief, it may seem difficult to figure out what to say, especially if you're inexperienced. Very often the patient appreciates the opportunity to talk about the damage, but his closest friends and family may have heard it all before, it can still be considered, so listening is often irreplaceable.

the trick! It is useful to know the patient has not received support from the social or voluntary work prior to admission. This means that if these services is to start the discharge, the patient is already known that the reference to the server, and it makes it easier. You will also need to check if the organization is aware of the fact that the patient is accepted, so that resources are not wasted.

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