A - E assessment Flashcards
Capillary refill time and observations and assessment for each component
1
Q
What is the A-E approach?
A
- A = airway
- B = breathing
- C = circulation
- D = disability
- E = exposure
2
Q
What are the considerations for a child in the A-E approach?
A
- 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
3
Q
What are the definitions for complete obstruction and partial obstruction?
A
- 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.
4
Q
What can cause obstructions to the airway?
A
- Secretions
- Blood
- Vomit
- Food
- Foreign objects e.g toys
- Swelling/ inflammation
- Facial trauma
5
Q
What is the assessment for airway?
A
- 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.
6
Q
What is paradoxical chest?
A
The chest walls move in when taking a breath and out when exhaling.
7
Q
Breathing assessment
A
- 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.
8
Q
Respiratory assessment for adults.
A
- 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)
9
Q
Respiratory assessment for children.
A
- Nasal flaring
- Head bobbing
- Intercostal recession
- Subcostal recession
- Tracheal tug
- Additional sounds
- Exhaustion
10
Q
What parameters are evaluated in the circulatory assessment?
A
- Heart rate
- Pulse volume
- Capillary refill time
- Blood pressure
- Urine output
11
Q
Heart rate assessment
A
- 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.
12
Q
Definition pf Tachycardia and Bradycardia.
A
- Tachycardia = increased heart rate.
- Bradycardia = decreased heart rate.
13
Q
What can a weak and thready pulse indicate?
A
It is an indication of a reduced cardiac output.
14
Q
What does a strong pulse indicate?
A
It can be a symptom of sepsis.
15
Q
Definition og regularity and equality.
A
- Regularity = regular or irregular (an abnormal rhythm)
- Equality = present or absences of pulses.
