Subjective assessment

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Chapter 16

Subjective assessment

image Clinical hints and tips

Prior to starting the subjective assessment consider your verbal and non-verbal communication. The environment, your body language and your position in relation to the patient will influence the interaction.

History of present complaint (HPC)

image Clinical hints and tips

Some of this information may have been collected by other professionals. To avoid asking the patient the same questions again, look at other available notes. If the multidisciplinary team uses electronic records, these should be readily available.

The therapist’s questioning for this section will need to be targeted differently depending upon the type of condition (progressive or non-progressive) and the stage of the disease (acute or chronic). The important history to establish, is that leading up to the present complaint including:

Progression of the condition

The therapist should note any changes involving the initial symptoms up to the present time. In a chronic or progressive condition this may involve a long period of time. If this is the case an outline of the main history is sufficient. The history of the symptoms tells the therapist about the behaviour of the condition in the past and may therefore assist in goal setting and prediction of prognosis.

Analysis – With no new neurological symptoms this may indicate that Mr X’s present condition is the result of inflammation/exacerbation of existing plaques rather than the formation of a new lesion.

Other management

Be aware of the management regimes implemented by other professionals in the team as they may have implication for the assessment, treatment choice and overall management.

For example, a patient being fed using percutaneous endoscopic gastrostomy (PEG) may fatigue quickly and therefore the assessment may need to be carried out over 2–3 short sessions. As receiving proper nutrition is a high priority for this patient, the assessment should try and fit around the feeding timetable. Other considerations include the patient’s bladder and bowel management and communication strategies. This information should be easily accessible within the hospital setting but must also be pursued outside of this area. In the community setting, other non-healthcare agencies may be involved and their input must also be considered.

Past medical history (PMH)

At this stage, the therapist needs to investigate any other medical conditions and co-morbidities which may influence the patient’s clinical presentation and which will need to be taken into account during assessment, treatment, goal setting and predicting the functional prognosis for the patient:

Drug history (DH)

Knowledge of the medication taken at the present time by the patient is important in terms of any relevant contraindications to therapy treatment and any related side-effects which may influence the assessment and treatment. For example, some drugs include side effects such as nausea (dantrolene), drowsiness or postural hypotension (tizanidine).

The long-term drug management of some symptoms may also result in secondary problems for the patient. For example, antispasmodic medications that work systemically (baclofen and tizanidine) to reduce hypertonic muscle activity are not discriminatory and therefore also affect other non-hypertonic muscles. The long-term use of these medications to reduce general muscle activity can cause underlying muscle weakness and loss of function separate to the primary condition (Dones et al. 2006).

It is also important to establish how the patient administers their medication. Can they manage themselves or do they need help? Is this assistance physical or a problem with memory/understanding? Does the administration require special/nursing skill? This latter questioning may be more relevant outside the hospital setting, but it is certainly worth considering prior to discharge from hospital.

Social history (SH)

In order to plan the objective assessment, treatment, maintain a patient’s motivation and set appropriate realistic goals, the therapist needs a picture of what the patient was able to do before this incident compared with what they can do at present. The style of questioning will be dictated by many factors, including:

The level of function of the patient

It would be inappropriate to ask a patient who arrived at the department by bus whether he can walk to the bathroom by himself. However, if he reports the upper limb as his main problem then a detailed discussion related to how he washes, dresses and feeds himself is justified. It would also be inappropriate to blindly continue through the range of questions regarding mobility with a patient who is clearly severely disabled or at a very acute stage. Therefore it is necessary to be sensitive and adaptable with questioning and set the level and amount of data collected appropriately.

The following will give the therapist some idea of the type of information required:

Personal ADL (PADL)

The therapist needs to investigate both previous and present level of ability for:

Washing

Enquire do they wash in the bathroom or at the bedside?

If they go to the bathroom do they wash at the sink or in the shower? Is the shower over the bath or can they walk in? Are there rails to assist getting into the shower? If they use the shower do they stand for the entire time or do they have a shower seat?

Do they have and can they use a bath?

When washing, how much do they do themselves? Include areas where hygiene is important such as underarms, feet and hands. Include shaving for men.

The majority of people would prefer to wash themselves; if this is not the case the therapist needs to investigate why.

Is the patient physically unable to wash? Have they taken on a sick role? Are carers taking over needlessly to save time and not allowing the patient to be independent?

This depth of questioning may appear excessive, however to ask ‘Do they wash independently?’ may lead to an answer of ‘yes’ even though what actually happens is that their carer brings a bowl of water to the bedside and they wash while sitting on the bed. This is not truly independent.

Domestic ADL (DADL)

Questioning related to the present level of ability in these activities will not be relevant in a hospital setting. However, an understanding of the patient’s previous levels, to which they may strive, is appropriate. Where required investigate both previous and present levels for:

Mobility

Note that the patient’s mobility may change at different times of the day. This could relate to factors such as general fatigue, other non-related conditions, poor motivation or medications but when identified, should be investigated thoroughly. Enquire about these different aspects of mobility prior to the present condition and at present:

Environment

A detailed investigation around this topic is important in all areas but especially so in an outpatient and community setting and as part of discharge planning in the hospital setting. Although in some settings a home visit will be carried out prior to discharge, it is still useful to gain an overview of the patient’s environment to enable the therapist to give a personal focus to goals and treatment.

Do they live in a house, bungalow, flat, caravan?

Is access to the home manageable? Are there any steps outside? Is there a handrail on the steps/stairs? Which side is it on?

Ask about the general layout of their home? Is there a bathroom downstairs?

Is the area they live in urban/rural, hilly or flat? If relevant, make similar enquiries related to work and any separate venues used to pursue hobbies?

If problems related to the housing environment are identified and are not being managed, then the therapist is responsible for a referral to the appropriate agency (Occupational Therapy, Social Services, etc.).

Psychosocial

Psychosocial factors play an important part in the physical, cognitive and emotional wellbeing of the patient. However, sensitive questioning may be required and where issues arise that are outside the therapist’s area of competency, a referral to the appropriate professional is essential. The therapist should consider the following:

Personal factors

These maybe reported more frequently by close friends and relatives. For example, lack of confidence, low self-esteem, depression, anxiety, stress, challenging behaviour and lack of motivation. A sudden change in the role of the patient in relation to the family can cause great upheaval and stress for all and can have serious financial implications.

Planning the objective assessment

The role of the therapist is to interpret the information that the patient relates to them in order to plan the objective assessment and implement patient-centred goals and effective treatment. This requires clinical analysis of the subjective assessment in terms of:

Following this analysis, the therapist should be confident to start making decisions to ensure that the objective assessment is more focused. This skill takes time to develop but becomes easier with experience.

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