2.1 General assessment

An overview of a general assessment is suggested in Tables 2.1 and 2.2.

Table 2.1 General assessment: part 1

General observations If the patient looks well, and is reading the paper – they probably are well! You still need to make sure you do not miss any significant issues

• Face: colour, expression • Condition: clean and well groomed or neglected and unkempt? • Position: in bed, chair or ambulant? • Posture: slumped or upright? Still or restless? • Weight: overweight or underweight, emaciated? • Attachments: note presence of drips, drains and equipment • Skin: wounds, pressure areas, colour, temperature • Peripheries: clubbing, swelling/oedema, cyanosis

ABC
A quick check from the end of the bed can be crucial in establishing the stability of the patient
Always make sure that the patient is not in any immediate danger by assessing their Airway, Breathing and Circulation, and implementing basic life support if required Can you recognize these signs and do you know how to address them? If not, you need an update on basic life support

Table 2.2 General assessment: part 2

For all assessments, it is assumed that informed consent (as appropriate) is sought and documented
Database Compile initial database of key information from relevant sources, e.g. medical notes, nursing records, other staff, the patient, carers or relatives as appropriate	• PC • HPC • PMH • DH • SH
Subjective questions	• How patient is feeling today • Emotional status • Symptoms and pain • Fatigue • Specific problems

PC, presenting complaint or condition; HPC, history of present condition; PMH, past medical history; DH, drug history; SH, social history.

In any setting, your initial observation of the patient is key, as this will allow you to identify a situation that may require immediate action.

2.2 Acute respiratory assessment

Use the systems-based checklist (Table 2.3). Your main aim is to decide whether the patient has physiotherapy-related problems (such as sputum retention, volume loss, breathlessness or respiratory failure). You also need to determine whether the patient’s condition is stable enough for your selected physiotherapy treatments. The other main purpose of assessment is to identify any deterioration in the patient’s condition and ensure that appropriate actions are taken by the healthcare team.

Table 2.3 Systems-based assessment outline

Central nervous system (CNS)

• Level of consciousness (may use AVPU or GCS) • Sedation score • Pupils: size and reactivity • ICP • CPP • External ventricular drain (EVD) • Pain score and route of analgesia

Cardiovascular system (CVS) Renal system (Renal) Respiratory system (RS) Musculoskeletal system (MS)

ABG, arterial blood gas; AVPU, Awake, Voice, Pain, Unrouseable; BP, blood pressure; CPP, cerebral perfusion pressure; CVP, central venous pressure; CXR, chest radiograph; ETT, endotracheal tube; FM, face mask; GCS, Glasgow Coma Scale; HR, heart rate; ICP, intracranial pressure; MAP, mean arterial pressure; NG,nasogastric; UO, urine output.

The checklist assumes that the general assessment (Tables 2.1 and 2.2) has already been followed. Specific adaptations for patients in general surgery, critical care and medical settings are then provided (Tables 2.4–2.6). Depending on the setting, different elements may need to be included or omitted (e.g. pupil size may not be monitored regularly in a rehabilitation setting but may be more important in a critical care/intensive therapy unit (ITU) or surgery setting).

Table 2.4 General surgery: specific considerations

Database	• Note the history leading up to surgery and whether elective or emergency admission • Operation notes should be documented, including: – Name of surgery – Incision site – Findings and procedure – Surgery time – Postoperative instructions
CNS	• Adequate pain control is key to the optimal management of the surgical patient and must be assessed (see 3.45 Pain scoring)
CVS	• Haemoglobin levels, WCC, lactate and CRP are particularly useful for indicating postoperative complications, such as circulatory failure and infection (see 3.6 Blood results)
Renal	• Use fluid balance to help identify patients at risk of shock • Note dehydration, which could cause viscous secretions (see 3.58 Sputum assessment) Buy Membership for Pulmolory and Respiratory Category to continue reading. Learn more here