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Foundations of Advanced Assessment
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WEEK 1Foundations of Advanced Assessment
Background
The nurse practitioner (NP) has advanced clinical competency beyond that of a generalist nurse.
The NP conducts health history interviews and physical exams to gather data that informs
ordering diagnostic tests, formulating and prioritizing a diagnosis, prescribing treatment, and
making referrals for additional services. The quality of the health history and physical exam are
essential to ensure accurate diagnosis, treatment, and positive client outcomes.
Using the best available evidence is a crucial competency to achieve the best client
outcomes. Evidence-based assessment is foundational to evidence-based practice. With
evidence-based assessment, the NP uses research and theory to guide the selection of
assessment methods.
Assessment is a continuous decision-making process of data collection, data synthesis, and
interpretation to guide the next steps.
Clinical Encounters
A clinical encounter should be both provider-centered and client-centered. In the provider-
centered approach, the NP guides the interaction to ensure that all data needed is acquired to
help identify a problem and determine a treatment plan. This approach does not incorporate the
individual needs or perspectives of the client. In the client-centered approach, the client’s
concerns, feelings, requests, and perspectives are prioritized, which does not incorporate the
provider’s perspective and expertise. Integrating both the provider-centered and client-centered
approaches leads to a more complete picture of the client’s illness, improved satisfaction, and is
more effective at achieving desired health outcomes.
Client Assessments
There are two types of client assessments: a comprehensive assessment and a focused or
problem-oriented assessment (Hendrickson et al., 2019). The NP adjusts the assessment to the
situation based on the purpose of the exam, the severity of the client's problems, the setting,
and the time available. Examine the image below to identify the characteristics of both types of
assessment.
Focused Assessment versus Comprehensive Assessment Image
Description
Focused Assessment
, Addresses focused concerns or symptoms
Used for established clients during routine or urgent care visits
Health history and physical exams are focused on the problem
Includes:
o brief history of the present illness
o only the system related to the problem in the review of
systems Comprehensive Assessment
Used for new clients
Provides personalized information about the client
Strengthens the clinician-client relationship
Provides a baseline for future assessments
Provides an opportunity for health promotion education and counseling
Includes:
o extended history of the present illness
o at least two areas of past medical history, family history,
and social history
o at least 10 systems in the review of systems
Types of Data
The NP gathers subjective and objective information during the history and physical
examination. Subjective data includes symptoms that the client describes such as a sore throat,
headache, or pain. It also includes the client’s feelings, perceptions, and concerns. Objective
data includes the physical examination findings or signs observed. Information obtained from
the client during any part of the health history is considered subjective data. All physical
examinations, laboratory information, and test data are considered objective data.
Subjective versus Objective Data Transcript
Subjective Data versus Objective Data
Drag the following data examples to their appropriate
category. Examples of Subjective Data
Lower back pain
Fatigue
Stomach cramps
Immunization history
Examples of Objective Data
Heart rate
Blood pressure
Lung sounds
, Wound appearance
Ambulation description
Weight
Clinical Encounter Sequence
A skilled NP conducts effective clinical encounters in a structured and logical sequence while
building a relationship with the client. Click through the activity below to learn more about
the clinical encounter sequence.
Clinical Encounter Sequence t
Slide 1: Initiate Encounter
Review the clinical record
Ensure the client is comfortable
Clarify the goals/agenda for the encounter; balance provider and client goals
Establish rapport
Identify the client’s preferred title, name, and gender pronouns
Use “people first” language (i.e., a person with hearing loss, a person who uses
a wheelchair)
Slide 2: Gather Information
Identify the client’s chief complaint or reason for seeking care
Invite the client’s story using an open-ended approach
Gather information about the client’s perspective of the illness using the mnemonic FIFE
Conduct the health history interview
Gather information about past medical history, medications and allergies, family
history, personal and social history, and review of systems
Slide 3: Perform the Physical Exam
Conduct the exam based on the information obtained from the health history
Maintain client’s comfort and privacy throughout the
exam Slide 4: Explain and Plan
Assess and respond to the client’s needs for information
Negotiate and make decisions together
Utilize teach-back to ensure the client understands the
plan Slide 5: Close the Encounter
Leave time for the client to ask questions
Summarize the plans for future evaluation, treatments, and follow up
, Discover More
NPs should not assume the sexual orientation or gender identity of a client is the same as a
previous encounter or that it can be determined by behavior, appearance, or gender of partners.
The Centers for Disease Control and Prevention (CDC, 2021) offers guidance on inclusive
communicationLinks to an external site.. Consider using these questions to ask about sexual
orientation and gender identity:
“How would you describe your sexual identity?”
“How would you describe your gender identity?”
“What is the sex on your original birth certificate?”
The Interview
During the interview, the nurse practitioner (NP) must balance time, guide the interview, and
ensure the client feels heard and unrushed, while still gathering necessary data about the chief
complaint or presenting problem. The NP gathers information about the client’s symptoms,
clarifies attributes of each symptom, establishes the chronological order of information, and
begins to generate and test diagnostic hypotheses. The expert interviewer can extract the most
pertinent data in a short amount of time while also assessing a client’s mental status based on
how they answer questions.
** Basic Interviewing Techniques **. Important
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)
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