Assessment and documentation - WHO

1 Assessment and documentationChapter 4 Assessment of the person affected by BU and documentation of the findings lDocumentation of indicated POD interventionsburuliUlcer_ok 25/02/06 22:06 Page 17he Assessment of the person affected by BU is importantfor identifying problems and needs, which leads to planninginterventions. Two models of Assessment forms are includedin Annexes 1 and 2. Annex 1 was developed with healthworkers in the Ashanti region of Ghana in 2003, and Annex 2 wasdeveloped later for Cameroon. These forms can be adapted to the localsituation. Careful Assessment of each person s problems will help the healthworker choose which interventions are needed to best prevent of Assessment results will help the health worker tomonitor interventions to see if the desired results are being obtained. Routine periodic reassessments should be scheduled. During thephysical Assessment process, it is important to hear the person scomplaints and expectations of treatment.

2 Following the Assessment ,the person should be informed of the results and proposed interventions(including the benefits, the risks, the amount of time for hospitalization,and special care requirements). Treatment should be holistic, considering not only physicalimpairments and difficulties but also psychological functioning andsocial situation. Effective communication helps to minimize the anxietiesof the person and the family, and helps them see the importance of of BU patients and documentation of the findingsA POD patient Assessment form was developed and initially testedduring the Ashanti Region POD/Rehabilitation Workshop in 2003. ThisAssessment and documentationKEY POINTS Assessment of the person affected by BU isimportant for identifying needs, for planningappropriate interventions, and for monitoring theresults of the interventions to see if there is anyimprovement. Interventions are chosen based on the problemsidentified and are fully discussed with the personaffected.

3 documentation helps to inform other healthworkers about problems and interventions, so thatadequate follow-through treatment is provided. The results of interventions may depend oncorrectly selected and applied interventions, theattitudes, knowledge, and skills of the individualand the family, the socioeconomic situation, andan accessible health 25/02/06 22:06 Page 18example will be used in this manual to illustrate howto fill out an Assessment form (Figure )allows the health worker to document the person slesion sites, impairments, limitations with dailyactivities, and restrictions in social participation. Following the identification of problems, the healthworker chooses which interventions are indicatedand describes the intervention to be documentation helps in monitoring the resultsof the chosen interventions and in informing otherhealth workers of problems and forms have been developed to monitoroedema in the upper and lower limbs (Annex 3).

4 Arange of motion (ROM) Assessment form (Annex 4)was developed to document goniometric readingsof the most frequently involved joints of the upperand lower limbs. The ROM form can be used to recordpassive and active measurements the most helpfulare passive measurements. Health workers may findthe documentation of ROM is more easily done bydrawing the angles of the joints on paper and datingeach drawing. This approach helps the health workerand the affected person to see the changes in jointmovement (Figure ). Assessment and documentation19 Figure Buruli ulcer patient s POD Assessment form Ashanti region, GhanaburuliUlcer_ok 25/02/06 22:06 Page 19 Buruli ulcer patient s POD assessmentform Ashanti region, GhanaGeneral informationFill in the person s name, clinical record number(No.), address to be used for future contact, the villageor city where the person lives, the district and region,and the age at time of Assessment .

5 The sex (gender)of the person is identified by placing an Xin the boxmarked Mfor male or Ffor female. The diseaseclassification is marked with an Xin the box labellednew case( no previous history of or treatment forBuruli ulcer) or recurrent case( presenting withinone year with a further lesion at the same site or ata different site). Fill in the level of educationcom-pleted and the occupationprior to being diagnosedwith Buruli ulcer. In addition, include the current status;for example, if a student is the individual still goingto school or not?or if a worker is the individual workingor unemployed or, more generally, has the individualbeen required to change occupation or to retirebecause of the disease?). Each Assessment formshould include the date the POD Assessment wascompleted, including the day (dd), month (mm) andyear (yy).Body chart designThe location and extent of the Buruli ulcer lesionsshould be carefully drawn in.

6 This information isimportant for determining the parts of body involved,information that is useful for interventions involvingsplints and pressure garments. Assessment and documentation20 Draw the angle of the joint when passively measurements over changes of wrist contracture following 1 day of serial of range of motion (ROM) measurementsburuliUlcer_ok 25/02/06 22:06 Page 20 Location of lesionAn Xis placed under R(right side), L(left side), orunder both sides, at the location of the lesion (headand neck, thorax, back, abdomen, buttocks andperineum, upper limbs, lower limbs). Impairments(problems and complications)An Xis placed under R(right side), L(left side), orunder both sides, if a problem or complication isidentified. Active (AROM) and passive (PROM) rangeof motion is most easily determined by the healthworker. The angles of the joints are recorded on aseparate piece of paper, using different colour markingpens for each Assessment date (see example,Figure ).

7 Care needs to be taken that the sameposition is used each time. The results can beobserved by the patient, so that progress can be of pain Pain can be recorded on a numerical scale, usingthe following method. The person marks on a line from no pain to maximum pain , and the position of themark is measured with a 10-centimetre ruler. Both thepain experienced at the time of the Assessment , andthe greatest pain experienced within the last 24 hours,should be recorded. The person should indicate with the pain level currently being experienced (currentpain), and mark the line with an Xto indicate themaximum amount of pain experienced within the last24 hours (greatest pain). Maximum or severe pain isthat pain which is constant and interferes with theperson s normal daily activities (see Figures , , Annex 5). A colour pain scale is usually moreeasily understood by both adults and and documentation21 Figure colour pain scale indicator for childrenFigure colour pain scale indicator for adultsNo painNo pain120 MaximumpainMaximumpain345678910 Figure pain scale indicatorKEYC urrent pain =cmGreatest pain within the last 24 hX=cmburuliUlcer_ok 25/02/06 22:06 Page 21 Measurement of wound sizeDetailed measurements can be taken on separatepieces of paper to record wound size (Figure ),areas and degree of sensory loss, and the degree ofmuscle weakness (functional motor test).

8 Oedema control measurement of the upperand lower limbsThe most accurate way to measure oedema is witha volumeter. The limb is submerged in a standard-sizecontainer with a standard quantity of water and thedisplaced water is measured. If a volumeter is used,care needs to be given to proper cleaning of thecontainer between patients. This manual, however,describes a simpler technique using a measuring tapeor a cord to record measurements. Periodic measure-ments are taken at the same locations, in order topermit comparison with earlier measurements. Addi-tional Assessment forms are included in this manualfor recording oedema in the upper and lower limbs(Annex 3). Care must be taken not to position themeasuring tape at an angle or pull the tape too tightly(Figures , and ). Assessment and documentation22 Figure wound size and depthFigures & of the tape for oedema measurementDRAW AND DATEM easure the length and the width of thewound; the area of the wound is given by the fomula: length x width x The depth of the wound can also be 25/02/06 22:06 Page 22 Assessment and documentation23 Figure oedema measurementsMeasurements can be taken using string and/or a measuring can bemonitored by comparingmeasurements.

9 BuruliUlcer_ok 25/02/06 22:06 Page 23 documentation of activity limitations,participation restrictions, and otherActivity limitationThis section of the form should document theindividual s perceived difficulties with daily activitiesbecause of Buruli ulcer described by either theindividual or the caregiver. A direct Assessment offunctional limitation can be made using the BuruliUlcer Functional Limitation Score (BUFLS) includedin Annex restrictionThis section of the form describes the problemsthat the individual perceives as being experiencedwith family, other relationships, school, work, andcommunity because of Buruli ulcer. Assessment ofparticipation restriction is possible by using theparticipation scale (P-scale), which is included inAnnex any other problem or difficulty that theindividual describes or that you and documentation24 Figure measurement of wrist joint range of motion (ROM)Care needs to be given to axis the thumb interferes, the measurementsshould be taken on the ulnar side of can also be done same technique should be used eachtime and with the same person of motion measurementsRange of motion (ROM) measurements are mostaccurately taken using a goniometer (Figure ).

10 Passive and active joint range of motion gonio-metric measurement forms can be found in Annex4. Joint angles should be measured both passively(the health worker makes the movement of theaffected individual s joint to its fullest capacity) andactively(the individual makes the movement). Jointangles can also be measured and monitored withpaper drawings; this technique is recommended forthe field (Figure ). buruliUlcer_ok 25/02/06 22:06 Page 24 Assessment and documentation25 Figure ROM with paper drawingsMeasure with goniometerDraw goniometer on paperCompare ROM changesPosition and draw the ROMC omparison of goniometer, drawn angle and antideformity splint position buruliUlcer_ok 25/02/06 22:06 Page 2526 The assessor, other health workers, and the familyshould clearly know how to follow up and reinforceroutine interventions and how to do them correctly(specific treatment techniques are described inChapter 5 of this manual).