Introduction to clinical assessment for prescribers

Introduction

Clinical assessment is a process of collecting information about a person’s health status, function and wellbeing. It involves using a variety of techniques, including observations, tests, assessment tools or physical assessments, to create a series of findings that either identify an abnormality or inform differential diagnosis​[1–3]​.

There are many variables that determine the type of clinical assessment required, including the clinical setting, acuity of the patient, and whether the health need of the person is a mental or physical concern.

Pharmacists undertake a variety of roles, with many requiring the use of physical assessment skills, often related to their scope of prescribing practice and defined responsibilities. However, in all contexts, prescribers have a responsibility to recognise when a patient is acutely unwell or at risk of rapid deterioration in their physical or mental health. This article will focus on undertaking an appropriate assessment for these scenarios.

It is recommended that you read this article in conjunction with these resources from The Pharmaceutical Journal:

• Introduction to the prescribing consultation;
• Principles of effective history taking when prescribing;
• Principles of person-centred practice for prescribing;
• How to use clinical reasoning in pharmacy
• How to build and maintain trust with patients.

To help further expand your prescribing skills, additional related articles are linked throughout. You will also be able to test your knowledge by completing a short quiz at the end of the article.

Identifying appropriate assessment approaches

Clinical and physical assessments often follow the completion of a thorough clinical history. The information gained from the history will guide the development of the differential diagnosis and influence the approach to subsequent assessments​[4]​. A focused assessment may be completed if the history indicated a specific issue or the patient is being reviewed for a known health condition, whereas a general assessment may be required if the presentation is unclear, urgent or emergent, or if you are not familiar with the patient​[2]​.

Clinical assessments should be undertaken in an appropriate environment for the setting in which you are working and the condition the patient is seeking support for; this could be a designated consulting room, a quiet area of the pharmacy, or behind the closed curtains of a patient’s ward bed space.

The general assessment of a patient begins the moment you make contact with them, observing how they appear, their gait and ability to converse and interact with you. These elements all provide information to you about their health. From this initial review, you will need to determine what type of assessment is required next.

There are a variety of tools and approaches that prescribers can draw from when conducting a patient assessment. A selection of some of the most commonly used tools in clinical practice are summarised below.

ABCDE assessments

The ABCDE (airway, breathing, circulation, disability, exposure) assessment is a well established and structured approach for assessing patients in emergency situations or when faced with an uncertain acute scenario​[5–7]​. Its purpose is to identify and manage the patient’s most life-threatening issues first. The steps may be repeated at regular intervals to monitor the progress of the patient over time. It is increasingly utilised within primary and secondary care settings as an effective method for assessing a patient’s baseline health status, identifying unstable patients or individuals at risk of deterioration and for reducing mortality in hospitals​[8,9]​.

Airway

First, the airway (noise, mouth, larynx, pharynx, trachea, bronchi and bronchioles) should be assessed to ensure that it is able to fulfil the function of carrying air to the lungs. You will be observing to identify if there is an obstruction or potential obstruction. A reassuring feature of a stable airway is if the patient can talk normally in full sentences​[7]​.

In partial obstruction, there may be reduced air entry, which alters the breath sounds; for example, wheezes and whistles. The type of noise may guide the source and location of the obstruction and support the diagnosis. Gurgling usually indicates fluid in the mouth or upper airway, potentially from secretions or vomit. Inspiratory stridor (high-pitched sound) is indicative of partial upper airway obstruction, which may result from the presence of a foreign body, inflammation or oedema. This could be owing to laryngeal inflammation and forms part of the ‘red flag’ review for sore throat. An expiratory wheeze is more commonly recognised as a symptom of narrowed bronchi and bronchioles, as observed in chronic airway conditions, such as asthma and COPD​[3]​.

In full obstruction, there will be no breath sounds, with other signs, including paradoxical chest and abdominal movements and/or the later sign of cyanosis (blue coloration) of the mouth and lips. Decreased levels of consciousness may also be observed​[3]​.

Breathing

Assessment of breathing is distinct from the review of the airway and is focused on the effectiveness of the gaseous exchange. Consequently, you are observing for signs of respiratory distress, including signs or symptoms outside the normal respiratory parameters of talking comfortably, respiratory rate of 12–20 breaths per minute (bpm) and an oxygen saturation (SaO₂) of 96% or above (unless the patient has a personalised accepted target as part of their COPD plan) or more general symptoms of appearing anxious, sweating and needing to maintain an upright position to breathe.

Concerning signs include the patient being too breathless to talk, a respiratory rate below 12bpm (bradypnoeic) or above 25bpm (tachypnoeic), or SaO₂  below 91%. Other indicators of distressed breathing include altered chest expansion (asymmetrical, tracheal deviation, or use of accessory muscles) or the presence of cyanosis.

During the assessment, you should look, feel and listen for changes in breathing. Assess the depth, pattern and quality of the breathing for a cycle of 15 seconds and the respiratory rate for a full minute. Oxygen saturation should be measured using a validated pulse oximeter​[10,11]​.

Circulation

A review of the circulation encompasses a wider review of the circulatory system. The initial observation is a general inspection of the patient’s skin, noting changes in temperature, signs of pallor or cyanosis or obvious signs of trauma, including wounds or presence of significant haematoma.

The next step is assessing the presence, quality, rate and rhythm of the radial pulse. A normal pulse should be regular, strong and bounding. Deviations from this should be investigated as a cause for concern. An indicator of a deteriorating patient would be a thready, almost imperceptible, pulse. The pulse rate should be taken over one minute and be 51–90 beats per minute​[10]​.

Capillary refill time (CRT) can be measured by applying pressure to a fingertip for five seconds and then releasing the pressure and timing how long it takes for the skin blanching to resolve. A good cardiac output gives a CRT of less than two seconds​[12]​.

A blood pressure measurement is a good tool for assessing cardiac function; although, for the purpose of the ABCDE assessment, it is worth noting that the acceptable parameters are different to those recognised for the diagnosis and treatment of hypertension, with an acceptable systolic range of 111–210mmHg as a good indicator of haemodynamic status.

Later signs of reduced cardiac function include reduced urinary output (oliguria) and impaired consciousness.

Disability

The focus of this element of the assessment is on the central nervous system and reviewing the patient’s level of consciousness. Commonly used tools for assessing the level of consciousness include the AVPU scale and Glasgow Coma Scale​[13,14]​.

The cause of the altered state of consciousness will need to be explored and other neurological tests may be required. Note that a change in the patient’s alertness may present as confusion and a separate assessment may be required to ascertain if this is the patient’s baseline or an acute event requiring investigation and treatment, such as hypoglycaemia, stroke or head injury. It is pertinent to complete a blood glucose test as part of this element of the assessment to rule out hypoglycaemia (blood glucose below 4mmol/L).

Exposure

This is a review of the patient’s skin for indicators of disease and serious illness, including observing for rashes (e.g. meningitis, septicaemia, anaphylaxis), wounds, pressure injuries, sites of infection, bruising and haematomas. It is important to approach this assessment in a patient-centred way and protect the patient’s dignity, with particular consideration given to situations where bodily exposure owing to undressing is required. Reassuring features would include a person presenting with no remarkable changes to their skin surface or extremities.

National Early Warning Score

The information garnered from an ABCDE assessment provides the foundation for the National Early Warning Score. The approach uses an aggregated score based on respiratory rate, oxygen saturation, systolic blood pressure, pulse rate, new confusion or level of consciousness, and temperature, recorded on a standardised chart to determine the patients current state, risk of deterioration and when to refer for clinical escalation.

Glasgow Coma Scale

Unlike the AVPU approach, the Glasgow Coma Scale is a standard assessment for level of consciousness that uses a numerical system, allowing for a graded review. This may be useful for indicating smaller changes in consciousness. The patient’s behaviours associated with motor responsiveness, verbal performance and eye opening are independently assessed, with a score of 15 indicating full consciousness, and a score of 3 inferring coma or death​[14]​.

Clinical assessments for minor ailments and less serious conditions

Many prescribing pharmacists will be working in settings where patients present with minor ailments or less serious conditions, and you will need to assess their condition using either an assessment tool, physical assessment or both. An example of how this can be done in relation to sore throat is provided below. For a range of resources on minor ailments, visit The Pharmaceutical Journal‘s minor ailments hub page.

Tools to assess mental health conditions

A mental health assessment should be considered in parallel with physical assessment. While a full mental health assessment is likely to be conducted by a specialist, prescribers should be alert to the risk of common mental health comorbidities, such as depression and anxiety, and consider how the patient’s mental health may intersect with their physical health and influence the subsequent management plan.

Screening tools, interview questions and questionnaires can be used by non-specialists to assess for possible mental health conditions and a management plan. Commonly used screening tools include the Generalised Anxiety Disorder-7 Questionnaire and Patient Health Questionnaire-9 for depression​[18,19]​. These screening tools utilise a series of questions, with assigned scores to ascertain a person’s current anxiety or depression state, and may be used as part of a general health survey, a focused review or checking response to treatment​[20,21]​.

Another widely used tool is the mini-mental state examination. This is used for assessing the cognitive impairment of older adults, as part of the diagnostic criteria or reviewing progression of known cognitive impairment. The results are commonly used as part of medicines reviews and have greatest value for supporting people living with dementia​[22–24]​. Full consideration of the mental health assessment procedure is beyond the scope of this article but further reading on the subject has been identified below.

Questions for reflection

1. This article has considered a general approach to clinical assessment tools. As a prescriber, you are likely to be working in a specific clinical setting and within a defined scope of practice. Which assessment tools most apply to your scope and area of practice? Are there any additional approaches that you might be able to incorporate?
2. Consider the referral pathways available to you if you assess a deteriorating patient or patient that presents with red flag symptoms. Are your referral options clear in an emergency scenario?
3. Are you regularly accessing feedback on your clinical assessment skills? Consider asking a colleague to observe you undertaking a clinical assessment with a patient, utilising the supervised learning event tools available via the Royal Pharmaceutical Society’s post-registration foundation or core advanced pharmacist curriculum. The mini-clinical evaluation exercise and direct observation of procedural skills assessment tools would be particularly useful to demonstrate and reflect on your practical skills of clinical assessment.

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