Assessing a Patient with a Disability
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Please review the following Essential Components of an Assessment
along with the associated case study for Mrs. Kathryn Hanover, which is specifically aimed at conducting an assessment using appropriate communication strategies for a person with a disability.
Kathryn Hanover Case Study
Ms. Kathryn Hanover, a 60-year-old woman, comes to the outpatient clinic for an appointment with a primary health care provider. She is accompanied by her grown daughter. She has not been seen by a health care provider for over a year and a half. This is your first encounter with Ms. Hanover and you are assigned to obtain information about her and the reason for her health care visit.
Essential Components of Assessment
1. Identify disability as identified by the patient.
(It is essential to address the patient’s disability in the health history and physical assessment You will not upset the patient by asking about a disability; the patient is usually very aware of the disability and very knowledgeable about it, and likely will be distressed if you don’t consider the disability when you obtain a health history and complete a physical assessment. Examples of questions or probes to use to ask about patient’s disability: “Would it be okay if I ask you a few questions about your disability?” and “Please tell me about your disability.”)
When you enter the room, you note that Ms. Hanover is sitting in a chair. She looks comfortable and not in any acute distress. Alongside her is a motorized scooter. After introducing yourself, verifying the patient’s name with her and asking Ms. Hanover the purpose of the visit, it is appropriate to comment on the scooter: “Ms. H., can you tell me why you use the motorized scooter?” She responds, “I use it to get around when I am out of my house. I have used it for about three years.”
Because she has not reported why she is using the scooter, it is appropriate to ask: “Do you use it because of fatigue, issues walking, or another reason?” She replies, “I use it because of weakness of my legs and because I fall easily.” Your next response could be: “Can you tell me the cause of your muscle weakness and falls?” or “Do you have an underlying disability that causes your muscle weakness?”
In response to this question, Ms. Hanover responds: “I had polio when I was four years old. I did okay over the years, but when I hit about 50 years of age, I started noticing muscle weakness and I started to stumble a bit. I was diagnosed about six years ago with post-polio syndrome. The muscle weakness has increased and I have foot drop. So I wear splints on both lower legs.”
2. Assess patient's ability to communicate and participate in health history and physical assessment.
(Assume that the patient is able to participate in discussion and conversation rather than assuming that he or she is unable to do so because of the disability. Communicate directly with the person with a disability rather than to a family member or caregiver who is with the patient.)
Although Ms. Hanover’s daughter is with her, it is essential to discuss her disability with Ms. Hanover rather than to direct questions to her daughter. Since Ms. Hanover will be asked about her full health history and have a physical examination, it would be appropriate to ask if she has limitations that affect other parts of her body other than her lower extremities.
“Ms. Hanover, does the post-polio syndrome or other health problems affect other parts of your body in addition to your legs?” In response to that question she replies: “I have some weakness of my arms, too, but that is not as big a problem as the weakness of my legs.”
3. Identify accommodations and modifications (e.g., signing, large print, other, etc.) needed by person with a disability to participate in the health history and assessment.
(Determine what assistance is needed to transfer the patient safely from a wheelchair to an exam table so that a complete assessment, including pelvic or testicular and rectal exam, can be conducted if indicated. Arrange for an interpreter if needed [it is not appropriate for a patient’s family member or other accompanying person to serve as interpreter].)
In preparation for the physical exam that will be conducted by the nurse practitioner, it would be appropriate to ask Ms. Hanover if she needs assistance in transferring from the chair to the examination table when it is time for her to do so.
“How can I help you get on the exam table safely? Do you need assistance removing your coat and putting on a gown?”
4. Include all aspects of health history and physical assessment that would be included for all patients.
(The health history and physical assessment should address the same issues that would be addressed with a person without a disability. For example, the health history should include sexuality, sexual function, reproductive health issues, preventive health care practices, and lifestyle behaviors. Assume that a person with a disability participates in the same activities and behaviors as those without a disability.)
When obtaining the health history and conducting the physical assessment, it is important to ask the same questions you would ask of any other patient.
“Ms. Hanover, do you exercise regularly? What kind of exercise do you do? How often do you exercise? When was your last GYN exam? When did you have your last mammogram? Were you able to stand for the mammogram? Have you had a colonoscopy? Have you ever had a DEXA to assess your bone density? Are you sexually active?”
5. Use “person-first language” in interactions with and about persons with disabilities.
(Although some disability groups [e.g., the Deaf community] prefer to be identified by their disability [“the Deaf person”], most prefer NOT to be identified by their disability. Language that refers to the person first [“person with a disability”] rather than their disability is more acceptable.)
When referring to Ms. Hanover to other health care providers or staff, it is important to refer to her as “a woman with a disability (or post-polio syndrome) rather than as a “disabled woman.” If you refer to other individuals with disabilities when communicating with Ms. Hanover, it is also important to use person-first language rather than refer to them as “the disabled” or “disabled people.”
“Some women with disabilities have difficulty standing to have a mammogram or standing for the time it takes to have it done. Do you have difficulty doing so?”
1. Assess the effect of a patient’s disability on his/her ability to obtain health care.
(Assessment should address the interaction of person’s disability and health care, his or her ability to manage self-care activities, follow health care recommendations, and obtain preventive health screening and follow-up care.)
Many individuals with disabilities do not receive health care as often as is recommended because of transportation issues and other barriers, including failure of clinical facilities and staff to provide accommodations that enable them to participate in health care and screening, so it is important to ask about those issues.
“Ms. Hanover, has your disability (or post-polio syndrome) made it difficult to obtain required health care, such as GYN exams, mammography, or other screening or care? How has it limited your ability to receive care?”
2. Assess patient for abuse or risk for abuse (physical, emotional, financial, and sexual) by others (family, paid care providers, strangers).
(Questions should be asked privately when no one else, including family and care providers, is in the room or able to overhear the conversation. Questions specific to abuse of persons with disability include: Have they been prevented from using wheelchair, cane, respirator, or other assistive device; have they been refused help for important personal needs [taking medications, getting to bathroom, getting out of bed, getting dressed, getting food or drink]. If abuse is detected, assess patient’s access to accessible information, resources, shelters, and hotlines.)
After asking her daughter to leave the room for a few minutes, it is appropriate to ask Ms. H. if she has experienced any abuse or personal violence. Asking specific questions related to her disability may uncover issues that don’t affect individuals without disabilities.
“Ms. Hanover, do you feel safe? Have you ever had any concerns about your safety? Has anyone prevented you from using your scooter or other assistive devices? Has anyone prevented you from receiving the help or care you need?”
3. Assess the patient for risk of falls.
(Ask about previous falls and injuries due to falls. Ask about impaired balance, muscle weakness, changes in gait, changes in vision, confusion. Ask if assistive devices are available and used to prevent falls.)
Ms. Hanover has already indicated that she falls easily. So questions about her risk for falls are very relevant and appropriate.
“Ms. Hanover, can you tell me when (or in what situations) you are likely to fall? Tell me about the times you have fallen and any injuries you have had as a result of a fall. Do you have strategies to reduce your risk for falling and sustaining injury from falling?”
4. Assess patient for depression.
(Do not assume that depression is “normal” because a person has a disability. If a person with a disability has depression, treatment should be offered just as any other patient would have treatment offered.)
It is appropriate to ask Ms. Hanover if she has experienced bouts of depression and important to recognize that having depression is not a “normal” reaction to having a disability. Further, individuals with disabilities who are depressed should be evaluated and appropriate treatment for depression should be provided.
“Ms. Hanover, do you ever experience depression? Do you have days when your mood keeps you from wanting to get out of bed or leave the house or your room? Have you ever been treated for depression?”
5. Assess patient for secondary conditions or risk for secondary conditions.
(Secondary conditions are conditions that result from having a disability or result from treatment of a disability [e.g., pressure ulcers, injuries]. Identify barriers to health care that may increase risk of secondary conditions [e.g., lack of transportation, nonparticipation in health promotion activities].)
Ms. Hanover has already indicated that she falls easily, increasing the risk for fall-related injuries. It is important to determine if she is at risk for other secondary conditions, such as pressure ulcers and other health problems that may be related to transportation barriers or nonparticipation in health promotion activities, such as lack of exercise (weight gain, increased cardiovascular risks).
“Tell me about any injuries that you have experienced as a result of falling. What strategies have you used to reduce your risk for falling? What strategies do you use to reduce the risk of injury when you do fall?” “Are you able to get around for appointments and to meet your day-to-day needs? Does anything hold you back from being able to do things you would like to do?”
6. Assess what accommodations the patient has made at home or needs at home to encourage or permit self-care and independence. Identify accommodations needed during hospital stay or when out of the home.
(Accommodations may range from use of assistive devices or simple rearrangement of the home to structural modifications that enable the person with a disability to remain in the home and to participate safely in his or her preferred setting. Home care nurses and therapists [occupational or physical therapists] can be helpful in assessing the home environment and suggesting modifications that would increase the ability of individuals with a disability to function safely in their own home. Determine if patient has or requires a bladder or bowel management program, uses alternative approaches to eating and drinking fluids, or has had a procedure to make management of bowel, bladder, and nutrition possible [e.g., self-catheterization, urinary diversion, insertion of PEG tube, etc.).
“In addition to the motorized scooter that you use when outside your home, what assistive devices or accommodations do you use in your home, such as walker, cane, or crutches? Have you ever fallen when using your assistive devices, or when not using the devices or when transferring from the scooter? Do you believe that you use the devices safely? Do you have a need for other modifications or accommodations that would make it easier for you at home or when out of your home? Are you interested in having an evaluation by an occupational or physical therapist to meet with you or visit you at home to determine if other devices or accommodations might be helpful to you?”
7. Determine what preparation and accommodations are needed during hospital stays, emergency room or clinic visits, acute illness or injury, and other health care encounters to enable a patient with disability to be as independent as he or she prefers.
(Determine if facility staff members are informed about the activities of daily living for which the patient will require assistance. Determine if accommodations are in place and readily available to enable the patient to use his or her assistive devices (hearing/visual aids, prostheses, limb support devices, ventilators, service animals). Determine what plans or strategies are in place to minimize consequences of immobility because of surgery, illness, injury, or treatments.)
“Ms. Hanover in order to provide the best care for you while you are in the hospital, please tell me what type of assistance you need to transfer from the chair or scooter to the exam table (or from the bed to a chair). Is there any special way to provide this assistance so that we meet your need for comfort and safety? Other than your scooter, do you use any other assistive devices at home that would help you while in the hospital?”
8. Assess what accommodations and alternative formats of instructional materials (large print, Braille, visual materials, audiotapes, interpreter) are needed by the patient with a disability.
(Determine if patient instruction materials are consistent with modifications [e.g., use of assistive devices] needed by the patient with disabilities to enable him or her to adhere to recommendations. Determine if the modifications made in educational strategies address learning needs, cognitive changes, and communication impairment.)
Ms. Hanover wears glasses, but indicates that no other accommodations or alternative formats are needed for her to read and understand instructional materials. If she were hard of hearing or had significant visual impairment, alternative methods of providing educational information and instructions must be provided.
9. Assess engagement of patient with disabilities in health promotion strategies and the patient’s awareness of their potential benefits (e.g., improved quality of life, prevention of secondary conditions).
(Assess patient’s awareness of accessible community-based facilities [e.g., health care facilities, imaging centers, public exercise settings, transportation] to enable them to participate in health promotion.)
It would be important to ask Ms. Hanover about her knowledge or awareness of places where she can go for exercise or preventive screening that are accessible and can accommodate her.
“If you wanted to go to a gym or fitness center, is there one near your home that is accessible? Are the centers to have preventive screening accessible to you? Does the fitness center staff provide assistance to enable you to have screening done?”