A - E assessment Flashcards
Capillary refill time and observations and assessment for each component
What is the A-E approach?
- A = airway
- B = breathing
- C = circulation
- D = disability
- E = exposure
What are the considerations for a child in the A-E approach?
- Secondhand information from parents
- Uncooperative children
- Different equipment
- Safeguarding perspective
- May not report new signs e.g pain
- May provide false or misleading information.
- Higher metabolic rate
What are the definitions for complete obstruction and partial obstruction?
- Complete obstruction = no air passing through the airway and the individual is unable to speak or cough.
- Partial obstruction = less air is allowed through the airway, can include coughing and wheezing.
What can cause obstructions to the airway?
- Secretions
- Blood
- Vomit
- Food
- Foreign objects e.g toys
- Swelling/ inflammation
- Facial trauma
What is the assessment for airway?
- Look - look for paradoxical chest, abdominal movement, cyanosis and use of accessory muscles.
- Listen - can they talk? Are they wheezing? Are they grunting? Are they snoring?
- Feel - feel for inspiration and expiration.
What is paradoxical chest?
The chest walls move in when taking a breath and out when exhaling.
Breathing assessment
- Assessing how much effort the patient needs to breathe.
- Assess how effective their breathing is (02 saturations, oxygen requirements, arterial blood gas analysis).
- Has the respiratory inadequacy caused an affect on other parts/ systems e.g hypoxia can cause tachycardia.
Respiratory assessment for adults.
- Respiratory rate
- Depth, rhythm and equals chest expansion
- Tripod position
- Use of accessory muscles 5. Pursed lip breathing
- Mouth breathing/ nasal flaring
- Trachea position (deviation from mediastinal shift)
Respiratory assessment for children.
- Nasal flaring
- Head bobbing
- Intercostal recession
- Subcostal recession
- Tracheal tug
- Additional sounds
- Exhaustion
What parameters are evaluated in the circulatory assessment?
- Heart rate
- Pulse volume
- Capillary refill time
- Blood pressure
- Urine output
Heart rate assessment
- Asses the rate of the heart beat and be mindful of any pain, anxiety or fever which can cause tachycardia.
- Assess the pulse volume of the peripheral and central for presence, quality, regality and equality.
Definition pf Tachycardia and Bradycardia.
- Tachycardia = increased heart rate.
- Bradycardia = decreased heart rate.
What can a weak and thready pulse indicate?
It is an indication of a reduced cardiac output.
What does a strong pulse indicate?
It can be a symptom of sepsis.
Definition og regularity and equality.
- Regularity = regular or irregular (an abnormal rhythm)
- Equality = present or absences of pulses.
Assessing the colour and temperature of the skin.
- Cyanosis (blue) = lack of tissue oxygenation.
- Pallor (pale) = anaemia
- Mottling = can be due to shock
- Rashes = may indicate sepsis.
- Warm or cold
How do you measure Capillary refill time (CRT) in an adult?
- Apply cutaneous pressure for 5 seconds on a finger tip help at heart level with enough pressure to cause blanching.
- Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure.
What is the normal value for CRT and what does a prolonged CRT suggest?
- Usually less than 2 seconds
- Suggests poor peripheral perfusion.
What factors can impact a CRT result?
- Cold surroundings
- Poor lighting
- Old age
How do you measure CRT in a child?
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