Evaluation

S

A new pt was admitted to the ward from the Wellington St campus and required an initial sensory assessment done. He had suffered a traumatic injury (falling through scaffolding on a worksite) with multiple orthopaedic injuries, including a head injury of the frontal and parietal lobes. The pt was to be assessed on the ward whilst in bed. He will be under full spinal precautions including RIB flat until directed otherwise by his consultant.

T

Sensory assessment of the pt via the ASIA guidelines was to be conducted. The sensory assessment was needed to monitor and observe any signs of ascending or descending neurological changes.

A

I began the assessment by first introducing myself and fellow colleague to the pt, and describing what we would be assessing today. I proceeded to test the pts sensory status, using his face as the reference sensation (which was intact and normal) and comparing it with that of other dermatomal points across the body.

R

The pt was compliant and appeared to understand what we were asking of him as it was done, but needed reminding and further cues as to what he was required to do.

E

The pt may still have PTA, which would help explain his apparent cognitive difficulties and poor concentration. He showed patchy responses, and significant sensory loss from a high thoracic level bilaterally. He appeared to pre-empt or guess the required result and lacked insight as to right and wrong, and perhaps what we might want to hear from him. Taking this into account, I attempted to keep the questioning clear and concise, and referred back to his reference sensation (being the face).

 S

To eliminate any dishonest or false responses, the pt may need further explanation as to the reasoning for the ax (if emotionally able and appropriate?). Keeping the assessment to a short time frame may help with is concentration abilities, and some reassurance that there is no right or wrong answer for the assessment, as it’s to give the medical staff a good idea of where he is at and if his status has changed. My supervisor was with us for the assessment and found similar responses from the pt. His status was difficult to assess but showed that other factors can certainly make it harder to obtain accurate results.