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Course: Fundamentals of Nursing

Topic: Client Interview

The Nurses International Community

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Module Goals

Learners will be able to:

Define the client interview.
Explain the purposes of the client interview.
Discuss the phases of the client interview.
Identify the skills needed by the nurse to perform an effective client interview.
Provide examples of nursing documentation and the client interview.

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What is a Client Interview?

Walden University, 2021

Also known as a “health assessment”

Usually conducted upon admission

A way to gain information to most effectively treat the client

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Purpose of Client Interview

A way to get broad details from client to perform client-centered care.

Establish provider-client relationship through effective communication.

Typically starting with why client is being seen, then becoming more specific to gain more related information.

Srivastava, 2013

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Phases of client Interview

Nova Southeastern University, n.d.

Primary complaint
History of Present Illness
Past Medical History
Allergies
Current Medications
Familial History
Social History
System Review

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Phases of Client Interview

Nova Southeastern University, n.d.

Primary complaint

What client considers primary problem bringing them in

History of the Present Illness

Questions aimed toward the specific problem
Where does this affect
How long has it been affecting you
Describe the pain/feeling

Past medical history

Pertinent illnesses client had in past
Hospitalizations/Surgeries

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Phases of Client Interview

Allergies

What allergies client has and reactions
Medications, food, environmental

Current medications

Prescribed medications, Over the Counter medications, herbs, vitamins

Familial History

Pertinent present conditions in family

Social History

Exposures, drug use, alcohol use, diet

Nova Southeastern University, n.d.

Contact info: info@nursesinternational.org

When discussing allergies, it is important to mark these in the electronic medical record or client chart, as well as provide physical representation of any allergies the client might have. Typically, an allergy band that the client wears or a special sign in the room is provided to alert the medical team. This is an important part of the client interview. When asking about current medications, dosages prescribed and how the client is taking the medications should be recorded. The client does not always take the medication as it is prescribed and intended so those two numbers and frequencies may be different. Familial history can include pertinent conditions that may affect the client due to genetics, such as hypertension, cancers, thyroid disesase. Social history information gathering can impact care and should be assessed. For example, if the client is prescribed a certain diet to control their diabetes, but they are not following that diet at home, this could impact the client data.

Nova Southeastern University. (n.d.). Patient interview guide. Patient Interview Guide. https://cfsecure.nova.edu/peprx/documents/evaluation_ippe_commee_ii_medicationprofile.pdf

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Phases of Client Interview

Nova Southeastern University, n.d.

Systems review

Complete head to toe assessment
May focus on certain systems depending on client complaint

Contact info: info@nursesinternational.org

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Critical Thinking Question

What is the importance of a thorough client interview upon admission? And subsequent client interviews at the start of your shifts?

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Nursing Skills Needed

Active listening

Concentrating on client
Verbal and nonverbal cues for client to continue communicating

Guided questioning

Encouragement of continuation of client speaking
Begin with general questions to begin communication and move to specific questions

Body language

Eye contact, engaged posture, appropriate facial expressions
Mirroring patient positions, therapeutic touch

Walden University, 2021

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Nursing Skills Needed

Empathy

Shows understanding and caring
“I understand”

Validation and reassurance

Assuring client that their feelings are valid and believed

Summary

At completion, summarize the communication and interview to show the client is heard

Transitional care communication

Express the next steps of care and what they’re to expect

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Client Communication Model

AIDET Five Fundamentals of Client Communication

Acknowledge
Introduce
Duration
Explanation
Thank you

American College of Obstetricians and Gynecologists [ACOG], 2014

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Client Interview Models Examples

ACOG, 2014

The RESPECT Model

Rapport
Empathy
Support
Partnership
Explanations
Cultural Competence
Trust

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Rapport: Establish rapport. Attempt to connect to client at a social level, avoid judgement of client, do not make assumptions about client or their point of view

Empathy: Acknowledge client’s point of view and their feelings, seek for understanding

Support: Attempt to state and overcome barriers to care for client, seek support system for client if appropriate, assure client you are there to assist them

Partnership: Work with the client in their care, collaboration with client

Explanations: Check in with client for understanding of care and plan of care

Cultural Competence: Show respect for the client’s cultural beliefs and practices, Be cognizant of one’s own potential biases

Trust: Take time to establish trust with client, show that you are listening to client and acknowledging their beliefs and feelings

American College of Obstetricians and Gynecologists. (2014, February). Effective patient-physician communication. Committee opinion. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/effective-patient-physician-communication

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Client Interview Helpful Hints Examples

Srivastava, 2013

Use client’s preferred name

Get on patient’s level by sitting

Strategic use of silence and open ended questions

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Critical Thinking Question

How do the AIDET and RESPECT client communication models impact client interviews?

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Cultural Considerations

Certain cultural beliefs may be discussed during client interview.
When engaging in client centered care, ask client if there is any belief they have that may determine care.

Example: Jehovah Witness not accepting blood products.

Client may speak another language where a translator is necessary for client interview.
Familial support may vary between cultures.

Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee, 2020

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References:

American College of Obstetricians and Gynecologists. (2014, February). Effective patient-physician communication. Committee opinion. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/02/effective-patient-physician-communication

Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee. (2020, January 04). 12.2: Jehovah’s witnesses and blood transfusion. Transfusion handbook. https://www.transfusionguidelines.org/transfusion-handbook/12-management-of-patients-who-do-not-accept-transfusion/12-2-jehovah-s-witnesses-and-blood-transfusion

Nova Southeastern University. (n.d.). Patient interview guide. Patient Interview Guide. https://cfsecure.nova.edu/peprx/documents/evaluation_ippe_commee_ii_medicationprofile.pdf

Contact info: info@nursesinternational.org

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References:

Srivastava, S. B. (2013). The patient interview. Fundamental skills for patient care in pharmacy practice (pp. 1-35). Jones & Bartlett Learning. http://samples.jbpub.com/9781449652722/9781449645106_ch01_001_036.pdf

Walden University. (2021). Effective nursing health assessment interview techniques. Walden University Resource Articles. https://www.waldenu.edu/online-bachelors-programs/bachelor-of-science-in-nursing/resource/effective-nursing-health-assessment-interview-techniques

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