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) • Note the name of all infusions and be aware of what they do as they may have an impact on your treatment options
RS	• Focus on breathing pattern (especially expansion) and cough effectiveness to identify any respiratory complications associated with loss of volume, sputum retention or respiratory failure
MS	• Identify any PMH that might lead to functional limitations. Assess function prior to discharge as relevant, e.g. stair assessment, social work review

CRP, C-reactive protein; PMH, past medical history; WCC, white cell count.

Table 2.5 Critical care/intensive therapy unit: specific considerations

General	• Monitor ABC carefully throughout the assessment and focus on patient stability
Database	• History of accident (if appropriate) and investigations with results following admission • Note all injuries, any surgery that may have been required and any equipment that may limit how you perform your assessment, e.g. external fixators • Are spinal precautions being taken? If so all patients will be treated as unstable until proven otherwise, and this should be clearly documented. If you are not sure, treat as unstable
CNS	• If there is any suspicion of head trauma it is very important to monitor conscious levels
CVS	• Be vigilant for any signs of deterioration, loss of stability or impending circulatory shock
Renal	• Fluid balance is important to identify patients at risk of shock
RS	• Consider the mode of any ventilation and method of delivery, e.g. ETT or tracheostomy and note ventilator settings • RR: include set rate (from ventilator) and spontaneous rate (if the patient is doing some breathing on their own)
MS	• Note any limitations secondary to other injuries, e.g. positioning if spinal precautions being taken • Be aware of any potential loss of ROM– may need to consider splinting • Be aware of skin condition as this can have an impact on what you are able to do. The nursing staff are an invaluable source of information!

ABC, airway, breathing, circulation; ETT, endotracheal tube; ROM, range of movement; RR, respiratory rate.

Table 2.6 Medical patient: specific considerations

Database	• Establish a baseline of the patient’s ‘usual’ values as these may not be within the ‘normal’ range because of the patient’s underlying long-term condition • Determine the extent of any deterioration since previous admission/assessment and discuss the likely prognosis as this may affect your choice of active physiotherapy treatment and/or the use of NIV
CVS	• Be alert for any symptoms (e.g. bilateral ankle swelling) of right heart failure (cor pulmonale), which is a common complication of COPD
RS	• For patients in respiratory failure you may also include an assessment for NIV • Psychological factors are very important, e.g. the extent to which anxiety may be affecting breathlessness (see 3.8 Breathlessness (dyspnoea) scales) • Once the initial acute illness is addressed, you need to explore the factors that may have led to this acute episode. Investigate self-management strategies, such as inhaler technique, chest clearance at home, managing breathlessness, compliance with medication and smoking cessation

COPD, chronic obstructive pulmonary disease; NIV, non-invasive ventilation.

2.3 Rehabilitation assessment

Once decisions about the patient’s immediate management have been made, use the goal-oriented and functional checklists, which focus on helping patients achieve their potential or returning them to the status they were at before they deteriorated. You must continue to ensure that your patient remains medically stable, however, and so you may still need to incorporate aspects of the systems approach. A specific checklist for acute patients in the community is also provided (see Table 2.11).

Table 2.11 Acute community patient assessment

Check medical stability Is patient sufficiently medically stable to remain in community environment?

• Is required medical support available, e.g. oxygen therapy, regular observations? • What is risk of medical deterioration/relapse? Any risk factors, e.g. age, significant co-morbidities? • Can/will patient rapidly receive help if they deteriorate, e.g. rapid response teams, regular district nurse visits? • Do they need further complex medical intervention or treatment, e.g. scans/CXR/ABGs? Does this require admission to hospital? • Is medication optimized? Can prescribed medication be delivered at home? (e.g. intravenous antibiotics may require admission to hospital, depending on locality)

Check functional ability
Does the patient have sufficient functional stability to remain in the community environment? Social circumstances
Does the patient have sufficient social support to remain in the community environment?  

ABG, arterial blood gas; CXR, chest x-ray.

2.4 General surgery patients (Table 2.4)

2.5 Critical care/ITU patients (Table 2.5)

2.6 Medical patients (Table 2.6)

2.7 Goal-oriented assessment (Table 2.7)

Table 2.7 Factors to be considered in goal-oriented assessment

Musculoskeletal/neurological

• Pain • Reduced range of movement • Muscle weakness • Loss of balance or coordination • Sensory loss/altered sensation • Loss of function • Reduced exercise tolerance

Respiratory Psychological/cognitive Social Other factors

2.8 Functional assessment

2.9 Acute community patient assessment

Table 2.11 lists appropriate considerations for patients in the community. The reader is also referred back to Fig. 1.5 (see page 7).