A-E Assessment Flashcards
A
Airway
B
Breathing
C
Circulation
D
Disability - conscious state
E
Exposure
Airway: look
Type - own; nose or mouth, adjunct, artificial
Patient - can air flow through, not obstructed e.g. tongue, food, mucus or secretion
Airway: listen
Abnormal sounds - stridor, gurgling, wheeze, snoring
No sound - completely obstructed, air wont pass
Airway: feel
Air movement - feel air out through mouth, feel the lungs expand
Breathing: look
Colour - cyanosis; blue tinge, lack of oxygen
Mode of ventilation - self, non-invasive, ventilated
SpO2 and FiO2 - oxygen saturation and fraction of inspired oxygen
Pattern of breathing - how chest expanding
Accessory muscles
Sputum - dark, blood, thickness
ABGs
Chest X rays
Breathing: listen
Able to speak
Auscultation - 10 points on the front and 12 points on the back
Cough - strong, productive
Percussion note - middle finger on rib space then tap, lots of air then a louder sound, fluid than a stony dull sound, consolidation than a dull sound
Breathing: feel
Chest wall movement - apical vs diaphragmatic, expansion
Tactile fremitus - feeling sputum, bubbling
Circulation: look
Colour - loss blood to the toes and fingers, blue
Heart rate and rhythm - ECG
Blood pressure
Capillary refill time - colour return to the nail bed
Temperature - core, 37.5
Urine output and colour
Fluid balance - in and out, heart failure restrict
Limb oedema - heart failure, long standing
Circulation: listen
Blood pressure - manual, hearing for heart beat
Circulation: feel
Pulse - heart rate, strength and regularity
Skin temperature - cold peripherally
Assess for pitting oedema - swelling, DVT, press hand on the swelling and it leaves a mark/ imprint
Disability: look
Level of consciousness - high CO2 levels to become drowsy, ACVPU; alert, confused, voice, pain, unresponsive
Pupils
Blood sugars - very low means they might be unresponsive
Disability: listen
Verbal responses - appropriate, add up to the conversation
Agitation
Pain - VAS
Exposure: look
Patient position - slump, sitting, lying, leaning forwards, changing position so function better
Body habitus - physiological state, size, body shape; scoliosis
Muscle wasting
Attachments - e.g. drugs, drips, catheters
Wounds/ dressings
Signs of infection or bleeding
Finger clubbing
Nicotine stains
Mobility aids
General condition of the patient
Exposure: listen
Chest drains - bubbling, swinging
Alarms - attached to monitoring, check with others, may need medical assistance
Exposure: feel
Skin temperature - wound, infection
ROM/ muscle strength - can they actually do what we want them to do
