Clinical assessment of the orthopaedicand trauma patient

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Chapter 7
Clinical assessment of the orthopaedicand trauma patient

Rebecca Jester

London South Bank University, London, UK; Dudley Group NHS Foundation Trust, Dudley, West Midlands, UK

Introduction

The aim of this chapter is to provide an evidence-based discussion of assessment of the orthopaedic and trauma patient. The chapter adopts a person centred approach to the subject of assessment as it is important to remember that, although a person’s chief complaint will be a musculoskeletal problem, most are likely to have co-morbidities and psycho/social issues that relate to their problem. Practitioners will be using their assessment skills throughout the patient’s journey from initial presentation in primary care, emergency room or outpatients department to on-going evaluation following intervention or change in medical status. Throughout the chapter, where robust evidence exists, there will be critical application of research to approaches to assessment and examination. However, to date there is very little high level evidence to support many aspects of patient assessment/clinical diagnostics within trauma and orthopaedics affirmed by a dearth of systematic reviews. Therefore the information within this chapter is in the main based upon evidence from the following sources: formal education, symposia, conference presentations, non-research publications, expert opinion and reflections on clinical experience (the author’s and other clinical experts’).

Principles of clinical assessment

Clinical assessment can be defined as gathering both objective and subjective data for the purposes of generating differential diagnoses, evaluating progress following a specific procedure or course of treatment and evaluating the impact of a specific disease process. Examples of objective and subjective data can be found in Table 7.1.

Table 7.1 Types of subjective and objective data

Subjective data Objective
History – dependent on accuracy of patient and/ or family as historians Radiographic and other clinical investigations such as blood tests, MRI, CT
Patient reported outcome measures (PROMS), patients’ subjective perceptions of their symptoms and the impact on their quality of life and functional ability, mental health status Measurement of range of movement (ROM) using goniometry Base line observations such as blood pressure, weight, height, body mass index (BMI), temperature, heart rate
Pain assessment Measurements of limb length and muscle strength
Physical assessment including muscle, strength, palpation, auscultation and inspection.
Clinician measures such as timed get up and go test.

There are some important key principles related to assessment including:

  • introducing yourself
  • confirming the patient’s identity
  • explaining what the assessment is going to involve
  • gaining the patient’s consent for the assessment
  • establishing if the patient wants a family member or carer to be present during the assessment
  • good hand hygiene prior to and on completion of assessment/examination.

It is important to establish, either prior to or early in the assessment, if the patient has any degree of cognitive dysfunction. Communicating with patients with impaired cognition requires management of the immediate environment to reduce accessory noise and constant re-orientation to what you are doing and why. It is also important to establish that the patient has the mental capacity to consent to the assessment before proceeding. People with learning disabilities often are not supported well in acute hospitals (MENCAP 2007). Thoughtful communication involves minimising healthcare jargon, use of pictorial aids if appropriate and including a family carer. These can all help to alleviate anxiety during the assessment process. Non-verbal and para-verbal communication play a key role in putting patients with cognitive impairment or learning difficulties at ease during the assessment and enhancing the accuracy and quality of information elicited during the assessment.

It is important to:

  • Ensure the patient is comfortable and their privacy and dignity are maintained at all times during the assessment. Patients of either sex should be asked if they would like a chaperone present during any physical examination and unless the patient refuses (this should be documented) a chaperone should always be present during intimate examinations of patients of the opposite sex. The name and signature of any chaperone should be clearly documented.
  • Check the patient is not in pain, thirsty, hungry or needing the toilet prior to embarking on the assessment process. Also be mindful not to overtire older or frail patients with prolonged questioning, examination and clinical investigations. Patients may require a break and the assessment process may need to be phased to accommodate their needs.
  • When documenting the assessment ensure you record negative as well as positive findings. For example ‘patient reports no locking or giving way of the knee joint’.

Models and frameworks of patient assessment

It is important to adopt a systematic approach to patient assessment to avoid missing valuable information and to minimise repetition. Patient assessment should be inter-professional and a shared assessment document adopted. This approach enables the multidisciplinary team (MDT) to share information and avoid wasting the patient’s time by several health care professionals attempting to collect the same information. Approaches to patient assessment will vary depending upon patient needs; for example, whether the patient is presenting as an emergency with multiple trauma or a non-emergency with a painful joint/s or musculoskeletal dysfunction.

Emergency presentation

The patient presenting in the Emergency Department (ED) with severe or multiple injuries must have an urgent and systematic assessment to identify life threatening issues using Advanced Trauma Life Support (ATLS). In most healthcare organisations these observations will be recorded on a Modified Early Warning Score (MEWS) chart. See Chapter 16 for further detail regarding assessment of the patient following trauma.

Non-emergency, elective or planned presentation

Within orthopaedic care the medical model of assessment has predominated, with the main aim of the assessment being to understand the patient’s chief complaint/problem and arrive at a differential diagnosis. Traditionally, this has been solely within the remit of the medical profession, but in recent years a growing number of specialist and advanced nurse and physiotherapy practitioners have taken on this role. The medical model comprises:

  • taking a history to elicit the chief complaint or presenting problem
  • observation and inspection
  • physical examination using palpation, percussion and auscultation
  • assessing movement and strength
  • clinical investigations.

The medical model lends itself to the patient who is presenting with a clearly defined orthopaedic problem with minimal co-morbidities or without complex social or psychological issues. However, many patients within the orthopaedic setting have more problems than just a single chief complaint and require a more person-centred rather than disease-centred approach to their assessment. The medical model of assessment tends to focus on the disease process rather than the impact of the disease on an individual and the ideology of holistic health assessment is to review the individual as a whole, with a focus on their overall health needs rather than the disease.

There are several assessment frameworks or models that lend themselves to the person with multiple physical, social and psychological issues and which nurses may find useful to structure their assessment. Assessment is the first part of the nursing process (comprising assessment, planning, implementation and evaluation of care). Nursing models and theories seem to have lost favour in contemporary clinical practice which has become mainly target-orientated, but it remains important that nurses promote a holistic approach to assessment and care. An overview of the assessment component of these nursing or psychological models is presented below.

Roy’s Adaptation Model

This model, developed by Roy (1984), is based upon four modes; physiologic, self-concept (including body image and self-concept), role function and interdependence mode. This model lends itself particularly well to patients who are in the restorative phase following musculoskeletal trauma or spinal cord injury or those suffering with chronic conditions such as back pain and arthritis (see Chapter 6 for further reading on rehabilitation). The model focuses on assessing the patient’s behaviour and stimuli toward adaptation in each of the four modes. The physiologic mode includes:

  • oxygenation
  • nutrition
  • elimination
  • activity and rest
  • skin integrity
  • the senses
  • fluid and electrolytes
  • neurological function and
  • endocrine function.

The role function model includes:

  • primary role (age, sex, development level)
  • secondary role (relatively permanent positions requiring performance such as spouse, parent, sibling) and
  • tertiary role (freely chosen and relatively temporary such as employee, student).

The self-concept mode includes:

  • the physical self
  • body image
  • body sensations
  • the personal self – comprising self-ideal and self-expectancy and the
  • moral–ethical–spiritual self.

The interdependence mode is about:

  • support systems, both intrinsic and extrinsic to the individual, and their receptive/contributive behaviours.

Wellness framework

The wellness framework (Pinnell and de Meneses 1986) can be used to provide a systematic approach to data collection during the assessment process. It focuses on health and wellness rather than disease or ill health and uses the following categories:

  • Degree of fitness: exercise patterns, muscle strength, muscle and joint flexibility, body proportions (fat and muscle).
  • Level of nutrition: analysis of nutritional intake, patient’s knowledge of healthy nutrition, sociocultural beliefs about diet.
  • Risk appraisal/level of life stress: identification of patient’s risk factors to health, identification of sources of stress to the patient, the patient’s perception of stress and their coping patterns.
  • Life-style and personal health habits: habits regarding health behaviours, regular health screening, dental checks, alcohol/drug/smoking consumption, sleep and weight management.

The role of the nurse in orthopaedic care must incorporate promotion of healthy life styles and supporting patients to minimise risk such as the link between obesity and joint problems and the wellness framework lends itself well to this aspect of orthopaedic assessment.

Maslow’s hierarchy of needs

Maslow (1954) first developed his theory of motivation and personality. From this seminal work, a hierarchy of needs can be used to structure the assessment process. The needs are arranged in a pyramid based on the premise that until the lowest or most fundamental needs of the individual are addressed they are unable to move to higher levels of functioning. These levels of need are presented below in order (lowest to highest):

  • Physiological (survival needs) – Assessment of oxygenation, nutrition status, fluid balance, body temperature, elimination, shelter (home conditions and support) and sex (assessing individual’s concerns about resuming sexual activity following procedures such as spinal fusion or hip arthroplasty).
  • Safety and security (need to be safe and comfortable) – Physical safety: assess risk of falls; pressure sores, infection, VTE, pain assessment. Psychological security should be assessed in terms of the patient’s need for information and inclusion in decisions about their care and treatment.
  • Love and belonging – Elicit information about the patient’s social and family support.
  • Esteem and self- esteem – assess issues around body image and adaptation and coping and eliciting what the patient’s goals are.
  • Self-actualisation – assess the extent to which the patient’s full potential is being reached, their levels of autonomy and motivation.

The medical model

History taking

Taking a history has three principal functions:

  • Provision of data to inform decision making around differential diagnosis and treatment planning.
  • Initiates a medium by which a therapeutic bond is formed between patient and practitioner.
  • Creates a forum for education.

The importance of thorough and accurate history taking has been recognised for many years. It is very tempting for busy practitioners to try and steer the patient’s presenting signs and symptoms to fit a particular disease pattern by asking leading questions, but this can lead to an inaccurate diagnosis. Silverman and Hurst (1991) suggest that history alone can provide the correct diagnosis in approximately 80% of patients.

History taking comprises ten stages which should be followed in order:

  1. Chief complaint – elicit the chief complaint, using an open-ended question such as ‘What brings you here today’?
  2. History of the chief complaint –
    1. Provocative or palliative – what makes it worse or better?
    2. Quantity or quality – how often do you experience the problem?
    3. Region or radiation – is the problem localised or more diffuse?
    4. Severity or scale – how would you rate your problem?
    5. Timing – is there a particular time of the day or night associated with your problem? When was the onset of your problem and has it been constant or intermittent?
  3. Recapitulation – re-affirm with the patient at this stage that you have understood what their main problem is and the history of that problem as this allows any misconceptions to be resolved before proceeding further with the history.
  4. Family history – some musculoskeletal conditions have a genetic disposition such as rheumatoid arthritis. A genogram is the most systematic and succinct way to record a family history.
  5. Past medical history (PMH) – including all major illnesses, surgery and treatments. Patients may often forget significant aspects of their PMH and you may need to triangulate information with accessory information from the patient’s notes, further questioning based on their medication, and findings from inspection such as scarring indicating previous trauma or surgery.
  6. Psychosocial and occupational history
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