International Journal of Orthopaedic and Trauma Nursing (2015) 19, 162–169
International Journal of Orthopaedic and Trauma Nursing www.elsevier.com/locate/ijotn
CLINICAL ASSESSMENT SERIES
Clinical assessment in trauma and orthopaedic nursing Sandra Flynn a,*, Hannah Pugh b, Rebecca Jester c a
University of Chester, Liverpool Road, Chester CH2 1UL, UK University College London Hospital c School of Health and Social Science, London South Bank University b
The emergence of the extended role within nursing has in recent years become common place in clinical settings such as orthopaedics and trauma within the health service in the United Kingdom and in many other countries around the world (Kaasalainen et al., 2010; Sheer and Wong, 2008). Physical examination and assessment have traditionally been seen as a medical undertaking. However, nurses are now increasingly crossing traditional healthcare boundaries in order to cope with the demands placed on healthcare services. The Scottish Executive (2005) suggests that nursing is in a state of rapid change and now, as never before, the scope exists for nurses to develop their careers in response to service demands, professional aspirations, policy drivers and, most importantly, patient need. The acquisition of new knowledge, skills and attitudes, which help improve the patient’s experience and ensure patient safety, also enables nurses to observe their professional legal, ethical and regulatory framework (Scottish Executive, 2004). This ‘new frontier’ has been embraced by many nurses and one Delphi study of nurse practitioners conducted in Glasgow reported that all participants believed that their ability to practice physical examination skills made a positive contribution to the quality of patient care, retention of staff and job * Corresponding author. E-mail address: Sandra.fl[email protected] (S. Flynn)
http://dx.doi.org/10.1016/j.ijotn.2015.03.008
satisfaction (McElhinney, 2010). The researcher further reported that over 42% of the study participants, with an educational attainment that ranged from diploma to Master’s level, stated that they lacked confidence in their ability to physically examine the musculoskeletal system. A further study concluded that one of the problems associated with health sciences education is that of overcrowded curricula (Giddens, 2007), suggesting that further education such as stand-alone modules or modules as part of a degree or masters pathway may give practitioners room to hone their skills in a specialty. Despite the findings of this study there has been an unprecedented increase in the number and type of advanced practice roles, particularly in the acute care setting (Bryant-Lukosius et al., 2004; Hamric et al., 2013; Royal College of Nursing, 2012). This series of papers aims to provide an overview of the fundamentals of patient assessment and principles of orthopaedic physical examination required to achieve a comprehensive musculoskeletal assessment. From your examination you will be guided in deciding on appropriate diagnostic tests and investigations and be able to provide a clear baseline for comparison should the patient’s physical condition alter. This introductory paper discusses the principles of musculoskeletal assessment with subsequent papers providing region-specific assessment guidance. To become competent in
Clinical assessment in trauma and orthopaedic nursing musculoskeletal assessment practical training, including observation and assessment by an experienced practitioner, is required.
Assessment frameworks Accurate assessment provides information on the health status of a patient that can help the clinician and members of the multi-professional team determine the healthcare needs of the patient (Munroe et al., 2013). Assessment is considered a social, dynamic and interactive process in which the patient and the clinician play an integral part (Bryans and McIntosh, 2000). The components of assessment may comprise a comprehensive or focused approach, full health history and physical examination (Jarvis, 2012). The use of an assessment tool or framework can provide a structured approach to the process, helping to ensure an accurate and systematic assessment. In turn this may help to enhance patient care and management (Collins et al., 2011; Fennessey and Wittmann-Price, 2011; Zambas, 2010) and clinician performance (Munroe et al., 2013). The basis for clinical decision making is informed by the interpretation of the clinical findings, resulting in the recognition of abnormality, identification of a differential diagnosis, evaluating progress following treatment or evaluating the impact of a specific disease process (Baid, 2006; Jester, 2014).
History taking History taking is a key component of patient assessment and should be performed using a structured and systematic approach (Fishman et al., 2014). Clinicians gain information from visual and physical signs during the course of clinical examination but it is the art of good verbal communication that enables the clinician to obtain a comprehensive picture of the health and health problems of their patient. Consideration should be given to the type and quality of questions asked during history taking and throughout the physical examination where verbal and nonverbal clues can help to confirm or refute a potential diagnosis (Williamson and Thoms, 2014). History taking is facilitated by the use of templates (Fig. 1) which structure the process and help the clinician to follow a line of appropriate questioning so that relevant information is obtained and the risk of missing significant information is reduced. There is evidence to suggest that between 70 and 90% of medical diagnosis can be determined based solely on history (Fishman et al., 2014; Paley et al., 2011;
163 Sanders, 2009). Detailed clinical examination should not be ruled out and, together with information obtained through history taking, can help direct relevant investigations and confirm the diagnosis, which seldom differs from that assumed from the history (Khatter and Hathiram, 2012).
Orthopaedic physical assessment Types of examination Diagnosis of musculoskeletal conditions requires methodical and comprehensive assessment. It is recommended that a framework is used to guide the assessment process but that the type of assessment will vary depending on the patient’s condition. Specifically, initial assessment of a trauma patient will be completed using the A-E framework (see Fig. 2) but patients with chronic orthopaedic problems or less acute traumatic injury can be assessed over a longer period of time, beginning with a comprehensive history. The process of assessment includes history taking, examination, screening and diagnostic actions. Although history taking is important it only forms one part of the musculoskeletal assessment. The practitioner cannot fully assess a patient based solely on the history given. A thorough physical examination is an integral part of the comprehensive musculoskeletal assessment and, coupled with a competent assessment, will help guide the clinician in deciding appropriate diagnostic tests and investigations. Importantly, should the patient’s condition deteriorate or alter the practitioner has an accurate baseline for comparison (Magee, 2014). Musculoskeletal examination is performed in order to: • Assess patterns of pain • Locate joint abnormalities • Assess neurovascular status of the upper and lower limbs It is also important to establish the effect of pain and abnormal joint function on a person’s activities of daily living (ADL). As the clinician works through the examination further impact on ADL, as a result of any musculoskeletal injury or disease, will become apparent. For example, whilst undertaking evaluation of gait a baseline active range of movement (AROM) and passive range of movement (PROM) of the unaffected and affected limbs will assist the practitioner in determining if a difference exists between the two ranges. The information gathered will help the practitioner to construct a clinical picture to support a diagnosis.
164
S. Flynn Always introduce yourself and tell the paent who you are, start with“hello my name is”. Check you have the right paent i.e. check name, date of birth, address and NHS number. Tell the paent what you are going to do and remember to gain consent before you start the consultaon. • • •
• • • • • •
• • •
Paent details – name, date of birth, sex, occupaon. Depending on the problem it may be pernent to ask whether the paent is right or le handed. Presenng complaint – what problem is the paent presenng with (it is important to let the paent state the problem in their own words. History of presenng complaint – when did the problem start? Use SOCRATES to help structure your quesons. S – SITE O – ONSET C – CHARACTER – sharp, burning, ngling etc R – RADIATION (this refers to pain only) A – ASSOCIATED SYMPTOMS, any other symptoms noted by paent T – TIME , refers to duraon or course E – EXACERBATING or relieving factors S – SEVERITY (use scale of 1-10, 10 being worse pain ever) Ask the paent if they have undergone any tests or invesgaons for their current problem Past medical history – ask about any current or past medical condions, use of acronyms such as ‘MITJTHREADS’: (myocardial Infarcon, Thromboembolism, Jaundice, Tuberculosis, Hypertension, Rheumac fever, Epilepsy, Asthma, Diabetes, Stroke) can help you structure your quesoning Drug history – current medicaon ask the paent to tell you if they know why they take each one, dosage, reason for taking medicaon, allergies, side effects, compliance, over the counter medicaon, herbal remedies. Family history – relaves, are parents alive and well, illnesses that run in the family , siblings, children, grandchildren Social history – smoking, alcohol intake, drug abuse, occupaon, home circumstances, recenravel broad, pets, diet, exercise. Funconal or Systems enquiry (FE/SE) – this should be directed by case presentaon (i.e. emergency or planned) and provide an overview of the systems not covered in the history of presenng complaint. Such as cardiovascular, respiratory, gastrointesnal, genitourinary, addional musculoskeletal assessment. At the end of the consultaon you should recount the informaon obtained and ask the paent to confirm accuracy. Ask the paent if there is anything else they would like to add and whether they have any quesons. Finally, remember to thank the paent
Fig. 1
History template (Fishman et al., 2014).
At all times during the examination the practitioner must ensure the safety, privacy and dignity of the patient (Jarvis, 2012). Always obtain verbal or written consent prior to any examination and where necessary ensure a chaperone is present. Depending upon the presenting complaint the practitioner will employ one of the following types of examination: • Comprehensive • Focused A comprehensive examination involves a thorough head to toe physical examination and in-depth history taking, whereas focused examination refers to obtaining information relating to the patient’s
presenting complaint. Relevant background history is obtained to help the clinician either refute or confirm a diagnosis (Bickley and Szilagyi, 2013). Subjective information and objective data are also collected. Subjective information refers to details obtained from the patient during the course of history taking such as pain or numbness. Objective data refer to the information gathered as part of the examination process and/or investigations such as swelling of a joint or the results of radiological investigations (Bickley and Szilagyi, 2013). Throughout this series you will see a repeating pattern, which is worth committing to memory: observe/inspect; palpate; range of motion. This is the basis by which you will perform each and every physical examination and is the mainstay of most system examinations. The orthopaedic physical examination can be assisted by the results of clinical
Clinical assessment in trauma and orthopaedic nursing
Fig. 2
165
AIRWAY
• Check airway is patent and maintained • Can the paent speak? • Check for abnormal noises. • Check movement of the chest and abdomen.
BREATHING
• Observe rate, depth and paern of respiraon • Observe for symmetry of chest movement • Does the paent require use of their accessory muscles? • Check for signs of cyanosis • Check and monitor oxygen saturaon
CIRCULATION
• Check manual pulse and Blood Pressure • Assess_capillary refill me • Monitor urine output and fluid balance • Check for patent venous access? • Are there signs of internal or external haemorrhage?
DISABILITY
• Assess level of consciousness using AVPU • Blood glucose level • Pupil size and reacon • Observe for seizures • Pain assessment
EXPOSURE
• Perform head to toe examinaon, front and back
ABCDE approach to patient assessment (Greater Manchester Critical Care Skills Institute, 2014).
tests and investigations such as x-rays available to the practitioner prior to examining the patient. Assessments can be tailored for both inpatient and outpatient settings and for various levels of ability and patient understanding.
Observation/inspection The initial part of the clinical examination concerns the visual inspection of the patient and area of complaint; this is referred to as observation. The examiner scrutinises the external appearance of the patient and the relevant body part while the patient is eating, resting and/or during physical activity (Reider, 2005). The assessor then proceeds to undertake a closer inspection of the patient and area of complaint. It is important for the examiner to have a good working knowledge of the relevant anatomy in order to differentiate between normal and abnormal findings. When undertaking inspection the temptation could be to look solely at the area of complaint; however this could lead to a wrong diagnosis, for example, a patient who reports pain in the knee could be experiencing referred pain from a hip problem. The best time to begin observation is on first meeting the patient. For example, in a clinic setting inviting a patient to walk into the examination room
allows the practitioner the opportunity to observe automatic function and gait prior to any formal assessment taking place. In a formal setting some patients may feel they need to exhibit physical signs of their discomfort in order to be ‘believed’, particularly those who suffer from chronic pain (Werner and Malterud, 2003).This may be addressed by inviting patients with an upper limb complaint, for example to ‘hang up their jacket’ allowing function to be observed without any exaggerated pain behaviours that may be exhibited during formal assessment. Inspection should also take into account any mobility aids or orthotics the patient may normally use to function such as crutches, sticks, braces and slings. When undertaking your first formal visual assessment it is important to expose enough of the patient to be able to fully appreciate the reported problem or concern. This may involve asking the patient to remove clothing so it is very important to promote privacy and dignity wherever possible. The practitioner should, ideally, view the joints above and below the area of interest or concern. An examination should begin with the ‘well’ or ‘unaffected’ limb in order to gain an understanding of the patient’s normal appearance. This may lead the patient to become confused and point out your ‘mistake’ so it is important to explain your rationale to promote confidence and trust.
166 Inspection involves looking at pallor and skin condition, swelling and overall appearance. Any lesions, wounds or surgical incisions, new or old, should be noted as they can assist in diagnosis and action plans. Some fractures will result in an obvious deformity such as the shortening and rotation often (but not always) associated with a hip fracture. A sound knowledge of anatomy will allow the practitioner to note normal bony prominences and the resting position of the limb in question. Asking the patient to assume certain positions may highlight any deformity or irregularity. All findings, normal or otherwise, should be fully documented. The practitioner may find that drawing diagrams is useful in describing findings. Photographs are helpful but must be accompanied with a suitable consent form. The majority of healthcare establishments dictate that these should not be taken on a personal device or camera phone.
Palpation To palpate is to use one’s hands to examine parts of the body. This may cause patients to feel uncomfortable or embarrassed. Again, maintaining the patient’s privacy and dignity is of utmost importance throughout assessment particularly when touch is involved. A chaperone may be required or preferred in some circumstances. The practitioner should begin by feeling and examining the ‘well’ or ‘unaffected’ limb to get a sense of the patient’s temperature and condition. For example a small proportion of the population do not have a dorsalis pedis pulse so if this cannot be palpated in the well limb the practitioner will not be so concerned to find that they cannot find it in the affected limb. Start by gently holding or ‘resting against’ the area of interest or concern to feel for temperature. If you are specifically assessing for the presence of heat use the back of your hand on the limb/joint or just above the area for radiating heat. You may be able to feel other abnormalities such as areas of bogginess, tight compartments or fasciculations indicative of underlying pathology or injury. Again comparison between both limbs will assist in detecting abnormalities, although some conditions, rheumatoid arthritis for example, present bilaterally so this method can be unreliable. Feel surface anatomy including bony prominences. Some injuries may be easily palpated such as complete Achilles tendon ruptures, where a palpable gap may be obvious, or a scaphoid injury, where the ‘anatomical snuff box’ area specifically causes pain. Be very careful, however, not to cause unnecessary pain
S. Flynn and discomfort when examining patients as this can result in distrust and resentment or even cause further injury. Finish by documenting all findings, both normal and abnormal, using diagrams if required (although a description is usually adequate).
Range of movement/motion (ROM) The ‘range of movement’ is the term frequently used to describe movement of a joint (flexion/ extension, abduction/adduction, internal/external rotation). Extension occurs when the angle between the bones at a joint decreases. Flexion bends the joint so that the joint angle shortens; flexion is the opposite movement to extension (Reider, 2005). It is important to establish the range of movement of the joints under examination. This is known as measuring the range of motion. Each joint has what is termed a ‘normal’ range of motion and this is expressed in degrees. Range of motion can be described as active (AROM), referring to how much movement the patient is able to demonstrate independently, or passive (PROM); how much movement can be demonstrated by the examiner with no assistance from the patient. Joint range of movement will vary according to patient gender, age and body type (Hattam and Smeatham, 2010). There are a number of devices and techniques available to clinicians which measure joint range of movement. These include goniometers, hygrometers, radiographic images and arthrographs. One device commonly used is the goniometer which measures joint angles and range of motion. The measurement of joint angles forms an important part of comprehensive musculoskeletal assessment and is used by clinicians to determine the amount of active and passive joint movement (Norkin & White, 2009). A goniometer is used to measure joint angles and is essentially a protractor with extending arms. The goniometer is used as follows: (1) The procedure is explained to the patient (2) Align the device in neutral or zero position (3) The fulcrum of the goniometer is placed over the fulcrum of the joint to be measured (4) The stationary arm of the goniometer is aligned with the limb being measured (5) The arms of the goniometer are held in place whilst the joint is moved through its range of movement and the angles observed
Clinical assessment in trauma and orthopaedic nursing
Limited range of motion
(6) Document results Joint motion has traditionally been assessed as a pair of terms within three planes of movement: • Flexion/extension • Abduction/adduction • External rotation/internal rotation These movements are a simple classification and many joints in the body have the ability to perform more complex motion (Reider, 2005): • • • •
167
Right/left lateral rotation Opposition Inversion/eversion Pronation/supination
Sagittal Plane
Fig. 3
• • • • • • • •
Joint pain Mechanical problems (torn meniscus) Muscle spasticity Infection (septic arthritis) Inflammation (bursitis) Disease (such as osteoarthritis) Swelling Injury (fractures, dislocations)
Limited range of movement of a joint can impair function and reduce the patient’s ability to undertake the usual activities of daily living.
Furthermore, each pair refers to movement that occurs in one of the principal planes of the body whilst in the anatomical position. These are the sagittal, coronal and transverse planes and are illustrated below (Fig. 3). Each joint in the body has movement that is expressed in terms of ‘normal values’. As previously discussed the normal value of a joint will vary in individuals with musculoskeletal injury or disease (Reece and Bandy, 2010).
Coronal Plane
Limited range of movement denotes a reduction in the normal movement of a joint that can occur as a result of:
Special tests Following the basic physical examination including inspection, palpation and ROM assessment, the practitioner may have an idea of the potential causes. This is known as the ‘differential diagnoses’. In order to narrow these diagnoses down ‘special tests’ may be necessary. These tests are assessments carried out to isolate specific tendons, ligaments, muscles or joints and to identify any underlying injury or
Transverse Plane
The three basic anatomical planes (Jenni Collins).
168 pathology. These differ greatly from area to area so will be discussed in more detail in future papers. Knowledge of these tests will greatly improve the assessment skills of the practitioner and facilitate a more detailed examination. Following all the above, it will most likely be necessary, particularly in initial assessments of new patients, to arrange appropriate imaging or investigations. Again, this is very specific to the type of injury or concern and will be discussed in more depth in the later papers. In order to take advantage of imaging the practitioner should have a sound knowledge of the types of imaging available, their uses and their contraindications. Radiographs and computerised tomography result in exposure to radiation and should be used responsibly and according to local guidelines. Magnetic Resonance Imaging involves less risk and does not rely on radiation but is often associated with long waiting lists and high demand which can cause delays in diagnosis and treatment so it should be considered cautiously. Many healthcare organisations now require nurses to undertake training on this topic prior to requesting imaging (Royal College of Nursing, 2008). Likewise laboratory tests should be carried out according to findings and are useful tools in the diagnosis of musculoskeletal conditions, particularly inflammatory disease or where infection is suspected. Knowing what tests to order and how to interpret the results are all part of a thorough, holistic assessment.
Conclusion Using the basic premise of inspection, palpation and the assessment of range of motion followed by special tests and appropriate investigations, musculoskeletal physical assessment empowers nurses and promotes professional autonomy. It also helps to ease the demands on healthcare services by increasing the numbers of staff who can carry out holistic care and treat patients accordingly. Nurses need to use their professional integrity and have an awareness of their own limitations so that the patients’ wellbeing is not put at risk. Practitioners wishing to increase their knowledge and competence in musculoskeletal assessment must ensure they undertake appropriate education, training and supervised practice.
Acknowledgement Jenni Collins, Medical Photographer and Illustrator, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
S. Flynn
References Baid, H., 2006. The process of conducting a physical examination: a nursing perspective. British Journal of Nursing 15 (13), 710–714. Bickley, L.S., Szilagyi, P.G., 2013. Bates’ Guide to Physical Examination and History Taking, eleventh ed. Lippincott Williams and Wilkins, London. Bryans, A., McIntosh, J. (2000). The use of simulation and post simulation interview to examine the knowledge involved in community nursing assessment practice. Journal of Advanced Nursing, 31(5): 1244–1251. Bryant-Lukosius, D., DiCenso, A., Browne, G., Pinelli, J., 2004. Advanced practice nursing roles: development, implementation and evaluation. Journal of Advanced Nursing 48 (5), 519–529. Collins, T., McNicholas, A., Butler, S., 2011. Advanced practitioner comprehensive tertiary survey including incidental findings: improved communication and reduction of missed injuries. Journal of Trauma Nursing 18, 73–78. Fennessey, A., Wittmann-Price, R.A., 2011. Physical assessment: a continuing need for clarification. Nursing Forum 46, 45–50. Fishman, J.M., Cullen, L., Grossman, A., 2014. History Taking in Medicine and Surgery, third ed. PasTest, University of Oxford. Giddens, J.F., 2007. A survey of physical assessment techniques performed by RNs: lessons for nursing education. The Journal of Nursing Education 46 (2), 83–87. Greater Manchester Critical Care Skills Institute, 2014. Acute Illness Management. AIM Course Manual, fifth ed. Hamric, A.B., Hanson, C.M., Tracy, M.F., O’Grady, E.T., 2013. Nursing: An Integrative Approach, fifth ed. Elsevier Saunders, Missouri. Hattam, P., Smeatham, A., 2010. Special Tests in Musculoskeletal Examination: An Evidence-Based Guide for Clinicians. Churchill-Livingstone Elsevier, London. Jarvis, C., 2012. Jarvis’ Physical Examination and Health Assessment, sixth ed. Elsevier, London. Jester, R., 2014. Clinical assessment of the orthopaedic and trauma patient. In: Clarke, S., Santy-Tomlinson, J. (Eds.), Orthopaedic and Trauma Nursing: An Evidenced-Based Approach to Musculoskeletal Care. John Wiley & Sons Ltd., Oxford, pp. 69–79. Kaasalainen, S., Martin-Misener, R., Kilpatrick, K., Harbman, P., Bryant-Lukosius, D., Donald, F., et al., 2010. A historical overview of the development of advanced practice nursing roles in Canada. Nursing Leadership 23 (Special Issue), 35– 60. Khatter, V.S., Hathiram, B.T., 2012. The importance of eliciting a good history from patients suffering from vertigo. Otorhinolaryngology Clinics: An International 4 (1), 1–4. Magee, D.J., 2014. Orthopaedic Physical Assessment (Musculoskeletal Rehabilitation). Saunders Elservier, St Louis: Missouri. McElhinney, E., 2010. Factors which influence nurse practitioners ability to carry out physical examination skills in the clinical area after a degree level module – an electronic Delphi study. Journal of Clinical Nursing 19 (21–22), 3177– 3187. Munroe, B., Curtis, K., Considine, J., Buckley, T., 2013. The impact structured patient assessment frameworks have on patient care: an integrated review. Journal of Clinical Nursing .
Clinical assessment in trauma and orthopaedic nursing Norkin, C.C., White, D.J., 2009. Measurement of Joint Motion: A Guide to Goniometry, fourth ed. F.A. Davis Company, Philadelphia: Pennsylvania. Paley, L., Zornitzki, T., Cohen, J., Friedman, J., Kozak, N., Schattner, A., 2011. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. Archives of Internal Medicine 171 (15), 1394–1396. Reece, N.B., Bandy, W.D., 2010. Joint Range of Motion and Muscle Length, second ed. Saunders Elservier, St Louis: Missouri. Reider, B., 2005. The Orthopaedic Physical Examination, second ed. Saunders, Philadelphia. Royal College of Nursing, 2008. Clinical Imaging Requests from Non-Medically Qualified Professionals. RCN, London. Royal College of Nursing, 2012. Advanced Nurse Practitioners: An RCN Guide to Advanced Nursing Practice, Advanced Nurse Practitioner and Programme Accreditation. RCN, London.
169 Sanders, L., 2009. Every Patient Tells a Story. Broadway Books, New York. Scottish Executive, 2004. Framework for Nursing in General Practice. Edinburgh. Scottish Executive, 2005. Framework for Developing Nursing Roles. Edinburgh. Sheer, B., Wong, F., 2008. The development of advanced nursing practice globally. Journal of Nursing Scholarship 40 (3), 204– 211. Werner, A., Malterud, K., 2003. It is hard work behaving as a credible patient: encounters between women with chronic pain and their doctors. Social Science & Medicine 57 (8), 1409–1419. Williamson, T., Thoms, L., 2014. The Practical Pocket Guide to History Taking and Clinical Examination. Radcliffe Publishing., UK. Zambas, S.I., 2010. Purpose of the systematic physical assessment in everyday practice: critique of a “Sacred Cow”. Journal of Nursing Education 49, 305–310.
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International Journal of Orthopaedic and Trauma Nursing www.elsevier.com/locate/ijotn
CLINICAL ASSESSMENT SERIES
Clinical assessment in trauma and orthopaedic nursing Sandra Flynn a,*, Hannah Pugh b, Rebecca Jester c a
University of Chester, Liverpool Road, Chester CH2 1UL, UK University College London Hospital c School of Health and Social Science, London South Bank University b
The emergence of the extended role within nursing has in recent years become common place in clinical settings such as orthopaedics and trauma within the health service in the United Kingdom and in many other countries around the world (Kaasalainen et al., 2010; Sheer and Wong, 2008). Physical examination and assessment have traditionally been seen as a medical undertaking. However, nurses are now increasingly crossing traditional healthcare boundaries in order to cope with the demands placed on healthcare services. The Scottish Executive (2005) suggests that nursing is in a state of rapid change and now, as never before, the scope exists for nurses to develop their careers in response to service demands, professional aspirations, policy drivers and, most importantly, patient need. The acquisition of new knowledge, skills and attitudes, which help improve the patient’s experience and ensure patient safety, also enables nurses to observe their professional legal, ethical and regulatory framework (Scottish Executive, 2004). This ‘new frontier’ has been embraced by many nurses and one Delphi study of nurse practitioners conducted in Glasgow reported that all participants believed that their ability to practice physical examination skills made a positive contribution to the quality of patient care, retention of staff and job * Corresponding author. E-mail address: Sandra.fl[email protected] (S. Flynn)
http://dx.doi.org/10.1016/j.ijotn.2015.03.008
satisfaction (McElhinney, 2010). The researcher further reported that over 42% of the study participants, with an educational attainment that ranged from diploma to Master’s level, stated that they lacked confidence in their ability to physically examine the musculoskeletal system. A further study concluded that one of the problems associated with health sciences education is that of overcrowded curricula (Giddens, 2007), suggesting that further education such as stand-alone modules or modules as part of a degree or masters pathway may give practitioners room to hone their skills in a specialty. Despite the findings of this study there has been an unprecedented increase in the number and type of advanced practice roles, particularly in the acute care setting (Bryant-Lukosius et al., 2004; Hamric et al., 2013; Royal College of Nursing, 2012). This series of papers aims to provide an overview of the fundamentals of patient assessment and principles of orthopaedic physical examination required to achieve a comprehensive musculoskeletal assessment. From your examination you will be guided in deciding on appropriate diagnostic tests and investigations and be able to provide a clear baseline for comparison should the patient’s physical condition alter. This introductory paper discusses the principles of musculoskeletal assessment with subsequent papers providing region-specific assessment guidance. To become competent in
Clinical assessment in trauma and orthopaedic nursing musculoskeletal assessment practical training, including observation and assessment by an experienced practitioner, is required.
Assessment frameworks Accurate assessment provides information on the health status of a patient that can help the clinician and members of the multi-professional team determine the healthcare needs of the patient (Munroe et al., 2013). Assessment is considered a social, dynamic and interactive process in which the patient and the clinician play an integral part (Bryans and McIntosh, 2000). The components of assessment may comprise a comprehensive or focused approach, full health history and physical examination (Jarvis, 2012). The use of an assessment tool or framework can provide a structured approach to the process, helping to ensure an accurate and systematic assessment. In turn this may help to enhance patient care and management (Collins et al., 2011; Fennessey and Wittmann-Price, 2011; Zambas, 2010) and clinician performance (Munroe et al., 2013). The basis for clinical decision making is informed by the interpretation of the clinical findings, resulting in the recognition of abnormality, identification of a differential diagnosis, evaluating progress following treatment or evaluating the impact of a specific disease process (Baid, 2006; Jester, 2014).
History taking History taking is a key component of patient assessment and should be performed using a structured and systematic approach (Fishman et al., 2014). Clinicians gain information from visual and physical signs during the course of clinical examination but it is the art of good verbal communication that enables the clinician to obtain a comprehensive picture of the health and health problems of their patient. Consideration should be given to the type and quality of questions asked during history taking and throughout the physical examination where verbal and nonverbal clues can help to confirm or refute a potential diagnosis (Williamson and Thoms, 2014). History taking is facilitated by the use of templates (Fig. 1) which structure the process and help the clinician to follow a line of appropriate questioning so that relevant information is obtained and the risk of missing significant information is reduced. There is evidence to suggest that between 70 and 90% of medical diagnosis can be determined based solely on history (Fishman et al., 2014; Paley et al., 2011;
163 Sanders, 2009). Detailed clinical examination should not be ruled out and, together with information obtained through history taking, can help direct relevant investigations and confirm the diagnosis, which seldom differs from that assumed from the history (Khatter and Hathiram, 2012).
Orthopaedic physical assessment Types of examination Diagnosis of musculoskeletal conditions requires methodical and comprehensive assessment. It is recommended that a framework is used to guide the assessment process but that the type of assessment will vary depending on the patient’s condition. Specifically, initial assessment of a trauma patient will be completed using the A-E framework (see Fig. 2) but patients with chronic orthopaedic problems or less acute traumatic injury can be assessed over a longer period of time, beginning with a comprehensive history. The process of assessment includes history taking, examination, screening and diagnostic actions. Although history taking is important it only forms one part of the musculoskeletal assessment. The practitioner cannot fully assess a patient based solely on the history given. A thorough physical examination is an integral part of the comprehensive musculoskeletal assessment and, coupled with a competent assessment, will help guide the clinician in deciding appropriate diagnostic tests and investigations. Importantly, should the patient’s condition deteriorate or alter the practitioner has an accurate baseline for comparison (Magee, 2014). Musculoskeletal examination is performed in order to: • Assess patterns of pain • Locate joint abnormalities • Assess neurovascular status of the upper and lower limbs It is also important to establish the effect of pain and abnormal joint function on a person’s activities of daily living (ADL). As the clinician works through the examination further impact on ADL, as a result of any musculoskeletal injury or disease, will become apparent. For example, whilst undertaking evaluation of gait a baseline active range of movement (AROM) and passive range of movement (PROM) of the unaffected and affected limbs will assist the practitioner in determining if a difference exists between the two ranges. The information gathered will help the practitioner to construct a clinical picture to support a diagnosis.
164
S. Flynn Always introduce yourself and tell the paent who you are, start with“hello my name is”. Check you have the right paent i.e. check name, date of birth, address and NHS number. Tell the paent what you are going to do and remember to gain consent before you start the consultaon. • • •
• • • • • •
• • •
Paent details – name, date of birth, sex, occupaon. Depending on the problem it may be pernent to ask whether the paent is right or le handed. Presenng complaint – what problem is the paent presenng with (it is important to let the paent state the problem in their own words. History of presenng complaint – when did the problem start? Use SOCRATES to help structure your quesons. S – SITE O – ONSET C – CHARACTER – sharp, burning, ngling etc R – RADIATION (this refers to pain only) A – ASSOCIATED SYMPTOMS, any other symptoms noted by paent T – TIME , refers to duraon or course E – EXACERBATING or relieving factors S – SEVERITY (use scale of 1-10, 10 being worse pain ever) Ask the paent if they have undergone any tests or invesgaons for their current problem Past medical history – ask about any current or past medical condions, use of acronyms such as ‘MITJTHREADS’: (myocardial Infarcon, Thromboembolism, Jaundice, Tuberculosis, Hypertension, Rheumac fever, Epilepsy, Asthma, Diabetes, Stroke) can help you structure your quesoning Drug history – current medicaon ask the paent to tell you if they know why they take each one, dosage, reason for taking medicaon, allergies, side effects, compliance, over the counter medicaon, herbal remedies. Family history – relaves, are parents alive and well, illnesses that run in the family , siblings, children, grandchildren Social history – smoking, alcohol intake, drug abuse, occupaon, home circumstances, recenravel broad, pets, diet, exercise. Funconal or Systems enquiry (FE/SE) – this should be directed by case presentaon (i.e. emergency or planned) and provide an overview of the systems not covered in the history of presenng complaint. Such as cardiovascular, respiratory, gastrointesnal, genitourinary, addional musculoskeletal assessment. At the end of the consultaon you should recount the informaon obtained and ask the paent to confirm accuracy. Ask the paent if there is anything else they would like to add and whether they have any quesons. Finally, remember to thank the paent
Fig. 1
History template (Fishman et al., 2014).
At all times during the examination the practitioner must ensure the safety, privacy and dignity of the patient (Jarvis, 2012). Always obtain verbal or written consent prior to any examination and where necessary ensure a chaperone is present. Depending upon the presenting complaint the practitioner will employ one of the following types of examination: • Comprehensive • Focused A comprehensive examination involves a thorough head to toe physical examination and in-depth history taking, whereas focused examination refers to obtaining information relating to the patient’s
presenting complaint. Relevant background history is obtained to help the clinician either refute or confirm a diagnosis (Bickley and Szilagyi, 2013). Subjective information and objective data are also collected. Subjective information refers to details obtained from the patient during the course of history taking such as pain or numbness. Objective data refer to the information gathered as part of the examination process and/or investigations such as swelling of a joint or the results of radiological investigations (Bickley and Szilagyi, 2013). Throughout this series you will see a repeating pattern, which is worth committing to memory: observe/inspect; palpate; range of motion. This is the basis by which you will perform each and every physical examination and is the mainstay of most system examinations. The orthopaedic physical examination can be assisted by the results of clinical
Clinical assessment in trauma and orthopaedic nursing
Fig. 2
165
AIRWAY
• Check airway is patent and maintained • Can the paent speak? • Check for abnormal noises. • Check movement of the chest and abdomen.
BREATHING
• Observe rate, depth and paern of respiraon • Observe for symmetry of chest movement • Does the paent require use of their accessory muscles? • Check for signs of cyanosis • Check and monitor oxygen saturaon
CIRCULATION
• Check manual pulse and Blood Pressure • Assess_capillary refill me • Monitor urine output and fluid balance • Check for patent venous access? • Are there signs of internal or external haemorrhage?
DISABILITY
• Assess level of consciousness using AVPU • Blood glucose level • Pupil size and reacon • Observe for seizures • Pain assessment
EXPOSURE
• Perform head to toe examinaon, front and back
ABCDE approach to patient assessment (Greater Manchester Critical Care Skills Institute, 2014).
tests and investigations such as x-rays available to the practitioner prior to examining the patient. Assessments can be tailored for both inpatient and outpatient settings and for various levels of ability and patient understanding.
Observation/inspection The initial part of the clinical examination concerns the visual inspection of the patient and area of complaint; this is referred to as observation. The examiner scrutinises the external appearance of the patient and the relevant body part while the patient is eating, resting and/or during physical activity (Reider, 2005). The assessor then proceeds to undertake a closer inspection of the patient and area of complaint. It is important for the examiner to have a good working knowledge of the relevant anatomy in order to differentiate between normal and abnormal findings. When undertaking inspection the temptation could be to look solely at the area of complaint; however this could lead to a wrong diagnosis, for example, a patient who reports pain in the knee could be experiencing referred pain from a hip problem. The best time to begin observation is on first meeting the patient. For example, in a clinic setting inviting a patient to walk into the examination room
allows the practitioner the opportunity to observe automatic function and gait prior to any formal assessment taking place. In a formal setting some patients may feel they need to exhibit physical signs of their discomfort in order to be ‘believed’, particularly those who suffer from chronic pain (Werner and Malterud, 2003).This may be addressed by inviting patients with an upper limb complaint, for example to ‘hang up their jacket’ allowing function to be observed without any exaggerated pain behaviours that may be exhibited during formal assessment. Inspection should also take into account any mobility aids or orthotics the patient may normally use to function such as crutches, sticks, braces and slings. When undertaking your first formal visual assessment it is important to expose enough of the patient to be able to fully appreciate the reported problem or concern. This may involve asking the patient to remove clothing so it is very important to promote privacy and dignity wherever possible. The practitioner should, ideally, view the joints above and below the area of interest or concern. An examination should begin with the ‘well’ or ‘unaffected’ limb in order to gain an understanding of the patient’s normal appearance. This may lead the patient to become confused and point out your ‘mistake’ so it is important to explain your rationale to promote confidence and trust.
166 Inspection involves looking at pallor and skin condition, swelling and overall appearance. Any lesions, wounds or surgical incisions, new or old, should be noted as they can assist in diagnosis and action plans. Some fractures will result in an obvious deformity such as the shortening and rotation often (but not always) associated with a hip fracture. A sound knowledge of anatomy will allow the practitioner to note normal bony prominences and the resting position of the limb in question. Asking the patient to assume certain positions may highlight any deformity or irregularity. All findings, normal or otherwise, should be fully documented. The practitioner may find that drawing diagrams is useful in describing findings. Photographs are helpful but must be accompanied with a suitable consent form. The majority of healthcare establishments dictate that these should not be taken on a personal device or camera phone.
Palpation To palpate is to use one’s hands to examine parts of the body. This may cause patients to feel uncomfortable or embarrassed. Again, maintaining the patient’s privacy and dignity is of utmost importance throughout assessment particularly when touch is involved. A chaperone may be required or preferred in some circumstances. The practitioner should begin by feeling and examining the ‘well’ or ‘unaffected’ limb to get a sense of the patient’s temperature and condition. For example a small proportion of the population do not have a dorsalis pedis pulse so if this cannot be palpated in the well limb the practitioner will not be so concerned to find that they cannot find it in the affected limb. Start by gently holding or ‘resting against’ the area of interest or concern to feel for temperature. If you are specifically assessing for the presence of heat use the back of your hand on the limb/joint or just above the area for radiating heat. You may be able to feel other abnormalities such as areas of bogginess, tight compartments or fasciculations indicative of underlying pathology or injury. Again comparison between both limbs will assist in detecting abnormalities, although some conditions, rheumatoid arthritis for example, present bilaterally so this method can be unreliable. Feel surface anatomy including bony prominences. Some injuries may be easily palpated such as complete Achilles tendon ruptures, where a palpable gap may be obvious, or a scaphoid injury, where the ‘anatomical snuff box’ area specifically causes pain. Be very careful, however, not to cause unnecessary pain
S. Flynn and discomfort when examining patients as this can result in distrust and resentment or even cause further injury. Finish by documenting all findings, both normal and abnormal, using diagrams if required (although a description is usually adequate).
Range of movement/motion (ROM) The ‘range of movement’ is the term frequently used to describe movement of a joint (flexion/ extension, abduction/adduction, internal/external rotation). Extension occurs when the angle between the bones at a joint decreases. Flexion bends the joint so that the joint angle shortens; flexion is the opposite movement to extension (Reider, 2005). It is important to establish the range of movement of the joints under examination. This is known as measuring the range of motion. Each joint has what is termed a ‘normal’ range of motion and this is expressed in degrees. Range of motion can be described as active (AROM), referring to how much movement the patient is able to demonstrate independently, or passive (PROM); how much movement can be demonstrated by the examiner with no assistance from the patient. Joint range of movement will vary according to patient gender, age and body type (Hattam and Smeatham, 2010). There are a number of devices and techniques available to clinicians which measure joint range of movement. These include goniometers, hygrometers, radiographic images and arthrographs. One device commonly used is the goniometer which measures joint angles and range of motion. The measurement of joint angles forms an important part of comprehensive musculoskeletal assessment and is used by clinicians to determine the amount of active and passive joint movement (Norkin & White, 2009). A goniometer is used to measure joint angles and is essentially a protractor with extending arms. The goniometer is used as follows: (1) The procedure is explained to the patient (2) Align the device in neutral or zero position (3) The fulcrum of the goniometer is placed over the fulcrum of the joint to be measured (4) The stationary arm of the goniometer is aligned with the limb being measured (5) The arms of the goniometer are held in place whilst the joint is moved through its range of movement and the angles observed
Clinical assessment in trauma and orthopaedic nursing
Limited range of motion
(6) Document results Joint motion has traditionally been assessed as a pair of terms within three planes of movement: • Flexion/extension • Abduction/adduction • External rotation/internal rotation These movements are a simple classification and many joints in the body have the ability to perform more complex motion (Reider, 2005): • • • •
167
Right/left lateral rotation Opposition Inversion/eversion Pronation/supination
Sagittal Plane
Fig. 3
• • • • • • • •
Joint pain Mechanical problems (torn meniscus) Muscle spasticity Infection (septic arthritis) Inflammation (bursitis) Disease (such as osteoarthritis) Swelling Injury (fractures, dislocations)
Limited range of movement of a joint can impair function and reduce the patient’s ability to undertake the usual activities of daily living.
Furthermore, each pair refers to movement that occurs in one of the principal planes of the body whilst in the anatomical position. These are the sagittal, coronal and transverse planes and are illustrated below (Fig. 3). Each joint in the body has movement that is expressed in terms of ‘normal values’. As previously discussed the normal value of a joint will vary in individuals with musculoskeletal injury or disease (Reece and Bandy, 2010).
Coronal Plane
Limited range of movement denotes a reduction in the normal movement of a joint that can occur as a result of:
Special tests Following the basic physical examination including inspection, palpation and ROM assessment, the practitioner may have an idea of the potential causes. This is known as the ‘differential diagnoses’. In order to narrow these diagnoses down ‘special tests’ may be necessary. These tests are assessments carried out to isolate specific tendons, ligaments, muscles or joints and to identify any underlying injury or
Transverse Plane
The three basic anatomical planes (Jenni Collins).
168 pathology. These differ greatly from area to area so will be discussed in more detail in future papers. Knowledge of these tests will greatly improve the assessment skills of the practitioner and facilitate a more detailed examination. Following all the above, it will most likely be necessary, particularly in initial assessments of new patients, to arrange appropriate imaging or investigations. Again, this is very specific to the type of injury or concern and will be discussed in more depth in the later papers. In order to take advantage of imaging the practitioner should have a sound knowledge of the types of imaging available, their uses and their contraindications. Radiographs and computerised tomography result in exposure to radiation and should be used responsibly and according to local guidelines. Magnetic Resonance Imaging involves less risk and does not rely on radiation but is often associated with long waiting lists and high demand which can cause delays in diagnosis and treatment so it should be considered cautiously. Many healthcare organisations now require nurses to undertake training on this topic prior to requesting imaging (Royal College of Nursing, 2008). Likewise laboratory tests should be carried out according to findings and are useful tools in the diagnosis of musculoskeletal conditions, particularly inflammatory disease or where infection is suspected. Knowing what tests to order and how to interpret the results are all part of a thorough, holistic assessment.
Conclusion Using the basic premise of inspection, palpation and the assessment of range of motion followed by special tests and appropriate investigations, musculoskeletal physical assessment empowers nurses and promotes professional autonomy. It also helps to ease the demands on healthcare services by increasing the numbers of staff who can carry out holistic care and treat patients accordingly. Nurses need to use their professional integrity and have an awareness of their own limitations so that the patients’ wellbeing is not put at risk. Practitioners wishing to increase their knowledge and competence in musculoskeletal assessment must ensure they undertake appropriate education, training and supervised practice.
Acknowledgement Jenni Collins, Medical Photographer and Illustrator, Countess of Chester Hospital NHS Foundation Trust, Chester, UK.
S. Flynn
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