ABCDE Flashcards
What happens when we don’t do A-E Assessment?
Deterioration
- Due to not recognising the signs and symptoms of the illness
- If deterioration occurs escalate to a senior practitioner and ensure safety of the patient.
Airway (questions ask when checking airway)
Is the airway clear and patent? Can the patient talk? Is the patient unconscious? Do they need their airway protecting? Is there a possibility of spinal injury? Can you remove the obstruction?
Assessment of patient airway
Chin lift Head tilt Protecting the C-Spine Suction Airway adjuncts
Symptoms of airway compromise
Inhaled foreign body Blood in the airway Vomit/secretions in the airway Soft tissue swelling Local mass effect Laryngospasm Depressed level of consciousness
Breathing ( what to assess )
Rate Rhythm Depth 02 saturation Colour
Observations for breathing
Normal respiratory rate per minute
12-20
Brachynopnea- Slow respiratory rate
Tachypnoea- Fast respiratory rate
O2 saturation
Normal saturation rate 94-100%
COPD 88- 92>
Breathing inspection
Look out for cyanosis Shortness of breath Cough Stridor Kussmaul Symmetric or asymmetrical breathing Auscultation Chest X-ray Arterial blood gasesp
Circulation
Look out for Capillary refill time Limb temperatures Peripheral pulses Central pulses BP Heart rate and rhythm Urine output
Circulation observation
Normal resting heart rate 60-100 beats per minute
Tachycardia - high heart rate
Bradycardia- low heart rate
Normal blood pressure 90/ 60 mmHg and 140/90mmHg
Hypertension- high blood pressure
Hypotension- low blood pressure
Look out for fluid balance, pallor and oedema
Disability
ACVPU GCS Pupil equal and reactive to light? Verbalising Pain score Blood glucose
AVCPU
A-Alert V-Verbal/voice C- confusion P-pain U- unresponsive
Checking pupils
Check size and the symmetry of the patients pupils
Asymmetrical pupils may indicate intracerebral pathology like strokes etc
Exposure
Look out for
bleeding
Temperatures
And inspect the patient
Exposure- inspection
Inspect the patient’s skin for any rashes, bruises, open wounds, signs of infection.
Assess any IV
Assess for swelling, tenderness( normally on the patient’s calves)
Review the patients surgical wounds : haematoma, infection or active bleeding
Look out for catheter (catheter site ) and urine output also look out for signs of infections or fluid loss from surgical drains
Exposure- Bleeding
If there’s active blood loss
- Estimate the total blood loss and the rate of the blood loss
- Re-assess for signs of hypovolaemic shock ( eg hypotension tachycardia pre-syncope , syncope)
