Assessment Considerations in Disasters and Conflicts
Original Editors - Naomi O'Reilly
Introduction[edit | edit source]
In order to provide the best care and plan the best treatment a thorough assessment must be undertaken. It is the most important step in the rehabilitation process. The assessment process guides our clinical reasoning and enables informed decisions about the rehabilitation process to be made. Johnson and Thompson outlined that treatment can only be as good as the assessment on which it was based. Taking adequate time to carry out a thorough assessment of a patient is highly valuable to rehabilitation professionals in an emergency setting. It can save time by avoiding duplication later on, but can often be very challenging to complete.
Whilst each profession, and in some cases each clinical condition, may have their own specific assessment protocols, there are several core elements common to assessments. These are outlined below.
NOTE: Be wary in conflict settings of documenting any information that may place a patient at risk.
Database[edit | edit source]
Keeping a central record of the patients you see is critical to ensure they can be followed up, and also to inform the overall response patterns of need. Most services working in disaster and conflict settings will already maintain a database, but in the midst of an emergency, this can be disrupted or need adaptation. The purpose of a database is to enable effective tracking and follow-up of patients, and to enable overall reporting and contribution to a coordinated response. Suggested minimum requirements for rehabilitation database should include:
- Patient name
- Date of birth or age
- Telephone number (or number for family or friend)
- Type of injury / diagnosis (ideally as part of a response-wide classification system)
- Address of likely discharge destination if known
- Type of follow up required (including any additional medical, equipment or specialist rehabilitation input)
Subjective Assessment[edit | edit source]
The subjective assessment is used to provide a detailed picture of how the present condition affects the patient. Before seeing a patient, ensure you read any available documentation and obtain as much information as you can from their medical file and from medical colleagues (if available) and document this. This will help avoid patients having to face repeated questioning from medical staff, which is important given that they may have experienced extremely traumatic events and suffered significant losses. Where a patient remains unwell, family members or friends may also be able to provide information.
Don’t forget to introduce yourself and your role (in simple language) and remember that some patients may not know what a rehabilitation professional does. Initial introductions with patients should also identify what their expectations of rehabilitation and their recovery are.
Avoid asking unnecessary questions, but if a patient wants to talk about their experience, try to allow them time and listen to them, even if you are under pressure. Take note of their mental state including signs of confusion, low mood, anxiety or delirium.
History of Presenting Condition[edit | edit source]
- Date and Mechanism of Injury
- Extraction and Pre-Hospital Care
- Medical and Surgical Management to date, including:
- Where the management took place
- The results of investigations
- Any plans for further management
- Precautions, such as weight-bearing status
Past Medical History[edit | edit source]
Pay particular attention to anything that might impair their recovery. This includes (but is not limited to) the following:
- Does the patient have any co-morbidities and known health conditions?
- Has the patient undergone any previous unrelated surgery?
- Does the patient require special equipment, or have any technology dependency?
- Has the patient ever had an allergic reaction?
Medication / Drug History[edit | edit source]
- What medication is the patient using?
- Were they previously taking anything that was disrupted by the emergency?
- Do they have any known allergies to medications?
Social History[edit | edit source]
Completing a social history can be challenging in disaster or conflict settings, particularly when getting sensitive information (for example, loss of family members, destruction of homes). Where possible, this information should be taken from patient files or other sources, so that the patient does not have to keep repeating this information to multiple rehabilitation professionals.
Other factors to incorporate into a social history include:
- Languages spoken and literacy
- Is anyone accompanying them?
- Do they have to care for others (children, older relatives)?
- Do they have people who can care for them?
- Do they know where they can go after leaving the hospital?
Other standard questions that are typically included in a social history should also be included, such as:
- What is their occupation?
- What did they do for leisure?
- What religion are they? (may not always be appropriate to ask in some conflict situations)
- Smoking, alcohol and drug use (may impact on healing and recovery times)
Objective Assessment[edit | edit source]
Objective assessment involves the collection of data that you can observe and measure about your patient’s state of health. In the early stages of disasters and conflicts, it may not be realistic or appropriate to use comprehensive assessment tools, and objective assessments will need to be tailored to the specific needs of the patient and the setting. However, the basic findings of any assessment must be always documented.
What you assess is determined by the clinical presentation of the patient, but also by your specific training, role and the protocols of the organisation that you work for. Different organisations will take different approaches to assessment. Depending on your training, common objective assessments that you use might include:
Observation[edit | edit source]
Observation of your patient should include: behaviour including level of distress; posture; patterns of movement including gait and involuntary movements if applicable; oedema; pressure sores; deformities; any external fixation, surgical sites or wounds and dressings. Injuries and observations should be documented on a body chart (if available) as part of your record.
Try to coincide rehabilitation with dressing checks to allow for surgical site or wound assessment to monitor for any signs of infection. Do not undress a wound yourself unless you are trained to redress it or a colleague is available to do so.
NOTE: Signs of Wound or Surgical Site Infections
- Purulent discharge
- Delayed healing
- New or increasing pain
Consciousness[edit | edit source]
It is also essential to establish what level of consciousness the individual has before commencing assessment and to monitor for any changes in levels of consciousness. Consciousness can be measured with either the AVPU (Alert, Verbally Responsive, Pain Responsive or Unresponsive) or the more detailed Glasgow Coma Scale. The Glasgow Coma Scale Aid is available to download in a wide range of languages from here.
Vital Signs[edit | edit source]
Vital signs including heart rate, blood pressure, respiratory rate (including work of breathing), oxygen saturation levels and temperature should only be checked and interpreted if you are trained to do so as part of your role. These can also be checked from the medical records and show trends in vital signs over the previous hours and days. This can provide an early sign of complications, and determine whether the patient is suitable for participation in rehabilitation. It also guides treatment options.
NOTE: Signs of Sepsis (Blood Infection):
|Age||Heart Rate||Respiratory Rate||Systolic BP||Diastolic BP|
|Full Term||100 - 200||30-60||60-90||30-60|
Cognition[edit | edit source]
Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. In some cases, such as suspected acquired brain injury, a more detailed assessment of cognition may be required. However, most patients will need to complete a quick check of orientation, including:
- Person - What's your name?
- Place - Do you know where you are?
- Time - Do you know what day, month, year or season it is?
- Situation - Do you know what happened to you?
Respiratory[edit | edit source]
Respiratory conditions can affect breathing either through damage to the lungs or excess secretions. To ensure that the correct treatment is implemented, a thorough respiratory assessment should be carried out (as long as you are competent to carry out and interpret it). Respiratory assessment should include both a comprehensive subjective and objective component to get a complete understanding of the patient's function and baseline. As a minimum standard of respiratory assessment, a chest x-ray review, auscultation and palpation should be undertaken. You can read about a complete respiratory assessment here.
Pain[edit | edit source]
Pain is common with the type of injuries seen in disaster and conflict settings. Gaining an understanding of the type and distribution of pain can be useful, to help identify the cause of pain and whether it is improving or worsening. A good pneumonic PQRST offers support to remember the elements of a pain assessment;
|P||Provokes||What provoked the pain? What makes it worse? What makes it better?|
|Q||Quality||sharp, dull, squeezing, pressure, pounding, burning, stabbing, stinging or aching pain|
|R||Radiates||Does the pain move anywhere? Ask the patient to point to anywhere they feel pain.|
|S||Severity||Ask the patient to rate the pain on a scale - there are a wide range of pain assessment scales available including the visual analogue scale, numeric pain rating scale|
|T||Time||When did it start? Was the onset slow or sudden? How long has it lasted? Is it constant or intermittent? Have you had the pain previously? Is it the same as previously or is it different from last time?|
Range of Movement[edit | edit source]
Range of motion is the capability of a joint to go through its complete spectrum of movements. Range of motion of a joint can be passive or active; we should measure both during our assessment using a goniometer or inclinometer, where applicable. Active movements should always be checked first as it allows us to see both how far and how the patient moves the joint on their own. You can read about completing joint range of movement assessment here.
Muscle Strength[edit | edit source]
The role of muscle strength testing is to evaluate for any weakness following injury, which can either be a result of damage to either the tendon, muscle or nerve supplying the muscle. The most commonly accepted method of evaluating muscle strength is the Oxford Scale, also known as the Medical Research Council (MRC) Manual Muscle Testing Scale.
The following links demonstrate Manual Muscle Testing of specific joints and movements:
Muscle Tone and Spasticity[edit | edit source]
Muscle tone is considered the state of readiness in a muscle at rest. Resting tone provides us with a background level of tone from which we can function efficiently. It is defined by the resistance to passive movement, which is an expression of the stiffness of the muscle fibres. It is affected by neural factors and non-neural factors. Physical disorders can result in abnormally low (hypotonia) or high (hypertonia) muscle tone.
- Hypotonia is seen in lower motor neuron conditions like peripheral nerve injuries, which present clinically as muscle flaccidity.
- Hypertonia is seen in upper motor neuron diseases like acquired brain injury and spinal cord injury, which can present clinically as either spasticity or rigidity.
Function[edit | edit source]
Assessment of function is really important to gain an understanding of how the injuries impact on the patient and should include balance, mobility and transfers, and activities of daily living (e.g. toileting/washing/cooking) . While there are a number of Outcome Measures available to measure function like the Functional Independence Measure, the WHODAS and the Berg Balance Scale, in disaster and conflict settings you are unlikely to have time to use these in the early phase of response. However, these formal outcome measures may be useful in later stages.
You can also assess function without using a formal scale by simply documenting key tasks that the patient can and cannot perform including;
- Bed mobility
Tissue Viability Status[edit | edit source]
For patients with altered levels of consciousness, areas of diminished sensation or restricted bed mobility, it is a vital to monitor tissue viability during any assessment. Tissue viability assessment should consider skin integrity and monitor any pressure areas or ulcers. Screening of pressure ulcer risk factors should be incorporated into our assessment and can be completed with a screening tool like the Braden Risk Assessment Scale (Adults) or the Modified Braden Q Risk Assessment Scale (Children).
You can read about completing a tissue viability assessment here.
Nutritional Status[edit | edit source]
In disasters and conflicts, access to adequate nutrition can be limited. It is important to have some understanding of the impact of malnutrition and micronutrient deficiency particularly on healing. It is important to link in with other team members, like Dietetics and Nutrition around the management and the implications for participation in early rehabilitation.
Being able to assess for nutritional status is important, so that you can highlight individuals at risk to members of the team trained in nutrition. You can use the Mid Upper Arm Circumference (MUAC) to assess for malnutrition in both children and adults or the Malnutrition Universal Screening Tool (MUST) to assess for malnutrition in adults..
Psychological Status[edit | edit source]
Always consider the wider impact of the disaster on the individual. A distressed, confused or depressed patient is unlikely to want to actively participate in rehabilitation. The psychological status assessment should look at depression, anxiety, confusion and delirium. Quality of Life Measures may be of use including the WHOQOL-100, WHOQOL-BREF, Screening Questionnaire for Disaster Mental Health or WHO-UNHCR Assessment Schedule of Serious Symptoms in Humanitarian Settings (WASSS) (Field-test Version). Although in a disaster and conflict setting you are unlikely to have time to use formal outcome measures in the early phase of response, they may be useful in later stages. It is important to link in with other team members, like psychologists and trauma experts, if you have concerns.
Resources[edit | edit source]
Early Rehabilitation in Conflicts and Disasters, Humanity and Inclusion
The Role of Physical Therapists in Disaster Management, World Physiotherapy
Minimum Technical Standards and Recommendations for Rehabilitation, World Health Organisation
References [edit | edit source]
- Johnson J, Thompson AJ. Rehabilitation in a neuroscience centre: the role of expert assessment and selection. British Journal of Therapy and Rehabilitation. 1996 Jun;3(6):303-8.
- Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. Handicap International: London, UK. 2020.
- Ausmed. AVPU Assessment | Ausmed Explains.... Available from: https://youtu.be/p4P-HguQm30[last accessed 26/02/2022]
- Ausmed. Glasgow Coma Scale (GCS) | Ausmed Explains.... Available from: https://youtu.be/_BGMQDmwRmA[last accessed 26/02/2022]
- Mikelsons, C. (2008). The role of physiotherapy in the management of COPD. Respiratory Medicine: COPD Update, 4(1), 2–7 Available at https://www.semanticscholar.org/paper/The-role-of-physiotherapy-in-the-management-of-COPD-Mikelsons/e333d7621a7fddb06be0ff219e2336c352fe335c
- Cross J, Harden B, Broad MA, Quint M, Paul Ritson MC, Thomas S. Respiratory physiotherapy: An on-call survival guide. Elsevier Health Sciences; 2008 Nov 25.
- Aigars Caune. CardioRespiratory Assessment. Available from: https://youtu.be/rozpDa2MePU[last accessed 28/02/2022]
- Dr John Campbell. Assessment of Pain. Available from: https://youtu.be/2YmAdr9s0dE[last accessed 26/02/2022]
- Ausmed. PQRST Pain Assessment | Ausmed Explains.... Available from: https://youtu.be/1mEYCcPt5Cg[last accessed 26/02/2022]
- IDASS. The Goniometer. Available from: https://youtu.be/ZUF7tpkVAIY[last accessed 28/02/2022]
- Moore AR. A Review of Mental Health Screening Tools Used in Disaster Research (Doctoral dissertation, Yale University).