Assessment Interview for Care Plan

  1. Hi everyone!

    Tomorrow, it will be my first day/time interacting with a patient. I will go in and meet him/her. Then I will begin the interview process. Asking about med history, subjective, objective, etc etc.. You know what I mean right?

    Anyways, I'm looking for any kind of advice or hints to do this right. If the patient is asleep is it ok to wake him/her up? I was told yes.

    Another thing, Should I gather all my informartion from the Kardex/chart first and then interview or interview first then get the secondary information afterwards. I was thinking of getting/kardex/chart first, that way the patient can tell me anything I have missing.

    THANKS for all the help in advance
  2. Visit suki616 profile page

    About suki616

    Joined: Feb '02; Posts: 14


  3. by   SmilingBluEyes
    I used to go to the floor where I would be doing my clinicals and look up whom would be under my care the next day. Next stop was the Kardex to see what was currently going on with him/her...I also reviewed the charts for additional info and history. Then, after all this, I would knock, introduce myself and ask if it was a good time to talk. I would pull up a chair, and sit directly next to my patient and just start with small talk (if he/she was up to it). It breaks the ice a LOT. If the person is extremely ill or refuses to talk (or cannot) all you can do is glean as much info from the kardex and chart and maybe ask his primary nurse about what you might need to know. I wish you well. Hang in there; nursing school is a challenge but we need you in our ranks. If you have any further questions, please PM me. Always happy to help.
  4. by   CaliNurse
    Yes, look at the Kardex first. I still do this everyday. Somethings get missed in report and the Kardex if current is a good source of what has been going on with the patient lately.

    Use that info incorporated with what the patient tells you to get your total picture.

    I usually start off by asking them how they slept the night before. That will 90% of the time strick up a conversation on good terms.

    The other things I ask are how well is their pain being controlled and the good old how long has it been since your last BM. They other questions are dx. specific but these 3 I asked everyone.

    Good luck, You will learn and it will become as easy as striking up a conversation in class.

  5. by   RNConnieF
    The first step should be the Kardex, and read it carefully, you'd be surprised at the inconsist infromation i.e. PMH lumbectomy, hysterectomy on one line and five lines later Never had anathesia. I like meet that woman!! Your first questions should be about comfort i.e. pain, hunger , thirst, need for BR, then begin your interview based on the dx, presenting signs and symptoms, and treatments. Good luck, have fun!!
  6. by   purplemania
    be careful how you ask questions: I asked a lady once if she had hi blood pressure and was told no. Then I found out she was on BP meds. Her reason for saying no? Well, I don't have hi blood pressure when I take my meds. I asked a female teen if she was sexually active and got a no. Preg. test was positive. Her response was "I thought you meant recently". See, you can have fun and be a nurse too.
  7. by   frankie
    suki, Interviewing patients is always interesting. When I was in nursing school, I always went to the hosptial the day before clinical, read the charts, kardex, and generally got info about the patient. I still do that. When I am going into the hosptial to teach a patient, I read the chart on the hosp. computer system. I find knowing what's going on, where descrepancies are in charting (ex DL vs TL CVL), diagnosis, PMH,PSH,CC, etc...helpful. I still talk with the patient about everything, but I have a bit of background info. Hope this helps - frankie