Assessment Considerations in Disasters and Conflicts

Introduction

In order to deliver the best care and plan the best treatment, a comprehensive assessment is required. It is the most important step in the preparation process. The assessment process guides our clinical thinking and enables informed decisions about the rehabilitation program. Johnson and Thompson[1] argued that the treatment can only be as good as the research on which it is based. Taking the appropriate time to conduct a comprehensive assessment of a patient is invaluable to emergency medical personnel. It can save time by avoiding duplication later but can often be very difficult to complete.[2]

While each profession and in some cases each clinical setting may have its own specific assessment protocol, there are several key features common to assessments. These are described below.

NOTE: Be cautious in conflict situations about writing any information that could put a patient at risk.

Database

Keeping a basic record of the patients you see is important to ensure they can be tracked and also to inform the overall needs response process. Most businesses operating in disaster and conflict situations will already maintain a database but in an emergency this can be compromised or needs to be adjusted. The purpose of a database is to improve the tracking and follow-up of patients and to facilitate the reporting of all reports and to contribute to a coordinated response.[2] Proposed minimum requirements for a rehabilitation database should include:

• Patient name
• Gender
• Date of birth or age
• Phone number (or family or friend number) .
• Injury / illness identification (preferably as part of response-wide classification process) .
• Address likely to be removed if known
• Required follow-up procedure (including any additional medical equipment or specialist for restoration) .

Subjective Assessment

The psychoanalysis is used to provide a detailed picture of how the patient is affected by the current situation. Before seeing the patient be sure to read any documentation and get as much information as you can from their medical file and medical colleagues (if any) and write this down. This will help to avoid patients having to face repeated questions from doctors which is necessary given that they may have experienced more traumatic events and greater losses. Where a patient remains unwell family members or friends may also do so provides information.[2]

Don’t forget to introduce yourself and your services (in a nutshell) and remember that some clients may not know what a rehabilitation specialist does. The initial introduction to patients should also outline expectations for rehabilitation and recovery.[2]

Avoid asking unnecessary questions but if a patient wants to talk about their experience try to give them time and listen to them even if you are under pressure. Note their state of mind with low levels of psychotic symptoms psychological anxiety or depression.[2]

History of Presenting Condition

• Date and Mechanism of Injury
• Extraction and Pre-Hospital Care
• Medical and Surgical Services to date including:
  • Where the management took place
  • The results of investigations
  • Any plans for further management
  • Caution is like a weight-bearing condition

Past Medical History

Pay special attention to anything that can sap their energy. This includes (but is not limited to) the following:

• Does the patient have any co-morbidities and known health conditions?
• Has the patient had any previous unrelated surgery?
• Does the patient need specialized equipment or have a technical background?
• Has the patient ever had a seizure?

Medication / Drug History

• What medication is the patient using?
• Were they previously picking up everything the emergency had destroyed?
• Do they have any known allergies?

Social History

Completing a life history can be difficult in situations of disaster or conflict especially when sensitive information is obtained (for example loss of family members damage to homes). Where possible, this information should be obtained from the patients file or other sources so that the patient does not this information should be continually repeated to more professionals in the rehabilitation field.[2]

Other elements that should be included in the life history are:

• Languages spoken and literacy
• Is anyone accompanying them?
• Do they have to care for other people (children, older relatives)?
• Do they have someone who can take care of them?
• Do they know where they can go after they leave the hospital?

Other standard questions usually included in social history should also be covered, such as:

• What is their occupation?
• What did they do for leisure?
• What religion are they? (may not always be appropriate to ask in some conflict situations)
• Smoking, drinking, and drug use (may affect healing and recovery time)

Objective Assessment

Objective assessment involves gathering data about a patient’s health that you can observe and measure. In the early stages of disasters and conflicts, it may not be realistic or appropriate to use comprehensive assessment tools and objective assessments are required Tailored to the specific needs of the patient and the environment. However, the basic results of any assessment must always be documented. [2]

What you assess will depend on the patient’s clinical presentation, but also on your specific training role and your organization’s protocols. Different organizations will use different assessment methods. Evaluation against your common goals for training Your use may include:[2]

Observation

Observations of the patient should include: behavior including level of distress; posture; movement patterns, including gait and involuntary movements (if applicable); edema; pressure sores; deformity; any external fixation of the surgical site or wound and dressings. damage and observation should Recorded on the body chart (if available) as part of the record.

Try to combine rehabilitation with a dressing inspection so that the surgical site or wound is evaluated to monitor for any signs of infection. Do not undress the wound yourself unless you have been trained in dressing or have a colleague who can do so.

Note: signs of wound or surgical site infection redness warm swelling purulent discharge delays healing new or increasing pain malodorous

Consciousness

It is also important to determine the individual’s level of consciousness and monitor for any changes in the level of consciousness before starting the assessment. Awareness can use AVPU (Alert Verbally Responsive Pain Responsive or Unresponsive) or more detailed Glasgow Coma Scale. The Glasgow Coma Scale Aid can be downloaded in multiple languages here.

[3][4]

Vital Signs

Vital signs, including heart rate, blood pressure, respiratory rate (including work of breathing), oxygen saturation levels, and body temperature, should only be checked and interpreted if you have been trained as part of your duties. These can also be checked from medical records and show important trends Signs of past hours and days. This can provide early indications of complications and determine whether a patient is suitable for rehabilitation. It also guides treatment selection.

Note: Signs of sepsis (blood infection): Fever above 101°F (38°C) or temperature below 96.8°F (36°C) Resting heart rate above 90 breaths per minute Breathing rate above 20 breaths per minute breath.

Table 1. Normal Vital SignsAgeHeart RateRespiratory RateSystolic BPDiastolic BPPreterm120-20040-8038-8025-57Full Term100 – 20030-6060-9030-601 Year100-18025-4070-13045-903 Years90-15020-3090-14050-8010 Years70-12016-2490 -14050-80 Youth 60-10012-1890-14060-80 Adult 60-10012-1890-14060-80

Cognition

Cognition is the mental activity or process of acquiring knowledge and understanding through thought experience and the senses. In some cases, such as suspected acquired brain injury, a more detailed assessment of cognition may be warranted. However, most patients will need to complete a rapid examination Directions include:

• Person – What’s your name?
• Place – Do you know where you are?
• Time – Do you know what day month year or what time it is?
• Situation – do you know what happened to you?

Respiratory

Respiratory disorders affect breathing through lung damage or excessive secretions. To ensure proper treatment is administered, a full respiratory assessment (as long as you are able to perform and interpret it) should be performed. Respiratory assessment should Include comprehensive subjective and objective components to gain a comprehensive understanding of patient function and baseline. [5][6] As a minimum standard for respiratory assessment, chest x-ray, auscultation, and palpation should be performed. you can read the full Respiratory assessment here.

[7]

Pain

Pain is common among injury types in disaster and conflict settings. Knowing the type and distribution of pain can help determine its cause and whether it is improving or worsening. A good pneumonia PQRST supports keeping the following elements in mind pain assessment;

PProvokes What causes pain? What made it worse? What makes it better? QQuality Sharp, dull crushing pressure shock, burning, stinging, tingling or soreness RRadiates Does the pain move anywhere? Ask the patient to point out any areas where they feel pain. Scales – There are a variety of pain assessment scales available, including the Visual Analog Scale The Numeric Pain Rating Scale TTime When was it started? Slow onset or sudden onset? How long did it last? Is it constant or intermittent? Have you ever been in pain before? is it the same Was it before or was it different from last time?

[8][9]

Range of Movement

Range of motion is the ability of a joint to complete its full range of motion. The range of motion of the joint can be passive or active; we should measure it with a goniometer or inclinometer (if applicable) during the assessment. Active motion should always be checked first because it Allows us to see how far and how the patient moves the joint on their own. You can read about completing a joint range-of-motion assessment here.

[10]

Muscle Strength

Muscle strength testing is done to assess any weakness following an injury, which may be the result of damage to the tendon muscles or the nerves that supply the muscles. The most commonly accepted method of assessing muscle strength is the Oxford Scale, also known as the Medical Scale Research Council (MRC) Manual Muscle Testing Scale.

The following links demonstrate manual muscle testing for specific joints and movements:

Upper body lower body shoulder flexion hip flexion shoulder extension hip extension shoulder abduction hip abduction shoulder horizontal adduction hip adduction scapula elevation hip external rotation scapula adduction/adduction hip internal rotation elbow flexion knee knee flexion elbow extension knee extension hand arm flexion plantar flexion arm extension dorsiflexion

Muscle Tone and Spasticity

Muscle tone is considered the state of readiness of a muscle at rest. Resting tones provide us with a background tone level from which we can operate effectively. It is defined by resistance to passive movement, which is a manifestation of muscle fiber stiffness. it is subject to Neurological and non-neural factors. Physical disorders can cause abnormally low (hypotonic) or high (hypertonic) muscle tone.

• Hypotonia is seen in lower motor neuron disorders such as peripheral nerve injury that clinically manifests as muscle relaxation.
• Hypertonia is seen in upper motor neuron diseases, such as acquired brain injury and spinal cord injury, and can manifest clinically as spasticity or rigidity.

Assessment of muscle tone and spasticity is important because of its potential impact on functional capacity. Pitch can be assessed using the modified Ashworth scale or the Tardieu scale.

Function

Functional assessment is important to understand the impact of the injury on the patient and should include balance activities and transfers as well as activities of daily living (eg toileting/washing/cooking). While there are many outcome metrics that can be used to measure functional For example functional independence measures WHODAS and the Berg Balance Scale in disaster and conflict settings, you are unlikely to have time to use them in the early stages of response. However, these formal outcome measures may be useful at a later stage.

You can also assess function without the use of formal scales by simply recording key tasks the patient can and cannot perform, including:

• Bed mobility
• Transfers
• Mobility
• Toileting

Tissue Viability Status

In patients with altered levels of consciousness, decreased sensation, or limited bed mobility, it is critical to monitor tissue viability during any evaluation. Tissue viability assessment should consider skin integrity and monitor for any pressure areas or ulcers. Pressure Ulcer Screening Risk factors should be incorporated into our assessment and can be done using screening tools such as the Braden Risk Assessment Scale (for adults) or the Modified Braden Q Risk Assessment Scale (for children).

You can read about completing the Organizational Vitality Assessment here.

Nutritional Status

In disasters and conflicts, access to adequate nutrition may be limited. It is important to understand the effects of malnutrition and micronutrient deficiencies, especially on healing. It is important to network with other team members around management such as Dietetics and Dietetics and the impact of participation in early rehabilitation.

It is important to be able to assess nutritional status so that you can highlight individuals at risk to nutrition-trained team members. You can assess children and adults for malnutrition using the Mid-Upper Arm Circumference (MUAC) or the Malnutrition Universal Screening Tool (Must) Assess adults for malnutrition..

Psychological Status

Always consider the wider impact of a disaster on an individual. Patients who are distressed, confused, or depressed are less likely to want to actively participate in recovery. Mental status assessment should focus on depression anxiety, confusion, and delirium. Quality of life measures may be Use include the WHOQOL-100 WHOQOL-BREF Disaster Mental Health Screening Questionnaire or the WHO-UNHCR Assessment of Severe Symptoms in Humanitarian Settings (WASSS) (field-tested version) [11]. Although in disaster and conflict settings you are unlikely to have time to use formal Outcome measures that address early stages may be useful at later stages. Be sure to reach out to other team members, such as psychologists and trauma specialists, if you have concerns.