ABCDE Assessment For Every Topic Flashcards
ABCDE Assessment Asthma.
What is the first step of an ABCDE assessment for asthma?
- Assess the area for safety
- Early call for help
- Appropriate PPE
- Maintain dignity
ABCDE Assessment of Asthma
What do you conduct the Airway assessment in asthma?
Look, Listen and Feel Approach.
Look—> For chest + abdominal movements, use of accessory muscles 💪 . Is there a presence if blood/ vomit or foreign bodies in the mouth 👄, presence of swelling and assess the patients colour.
Listen —> listen for noises when when the patient is breathing such as wheezing, snoring, crowing, an inspiratory strider ( indicates collapse in tissue above vocal cords) or an expiratory wheeze.
Feel —> For airflow at the mouth and nose.
How do you assesses if someone had a patient airway, semi occluded airway, or fully occluded/ blocked airway.
- Patent —> patient has no issues communicating
- semi- occluded —> Can cough and you can hear sounds such as wheezing, gurgling, snoring 💤 etc
- Fully occluded/ Blocked —> Patient appears to cough but you cannot hear any sounds.
ABCDE Assessment
In an Asthma attack what would you expect to observe during an airway assessment?
- wheezing
- Cyanosis of the lips
- Respiratory distress
- Use of accessory muscles
Don’t forget to go into detail in the exam about what causes these at a cellular level.
ABCDE Assessment for Asthma
How do you conduct the breathing assessment in asthma?
Look, Listen, Feel approach.
Look —> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips 👄 and tongue 👅. Ability to hold a conversation. Position of the trachea.
Listen —> Ability to cough 😷, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.
Feel —> Chest Movement
ABCDE Assessment of Asthma
In an asthma attack what would you expect to observe during the breathing assessment?
- Respiratory distress due to acidosis
- Cyanosis
- Use of accessory muscles
Please explain these in detail when in the exam
ABCDE Assessment
How do you conduct a circulation assessment in asthma?
Can be done by working your way either up or down an arm
- Assess Heart ❤️ rate, rhythm 🎶, and amplitude
- Assess BP ( if low possible bleeding)
- Assess colour of hands + fingers (cyanosis)
- Assess limb 🦵 temperature 🤒
- Assess capillary refill time
- Consider urine output ( if BP is low urine out put will be low)
- nausea or vomiting 🤮 ? ( low BP can cause vomiting 🤮 and nausea)
ABCDE Assessment of asthma
In an asthma attack what would you expect to observe during a circulation assessment?
- Expect them to be cardiovascular 🫀 unstable due to a lack of O2
- I would expect them to have a low BP due to the lack of O2 effecting the function of the heart
- Due to the low BP I would expect them to have a low urine output
- cyanosis of the extremities such as the fingers or toes.
- if the patient is frightened I would expose the them to have a fast heart rate due to the adrenaline
ABCDE Assessment of Asthma
How do you conduct a disability assessment in asthma?
Assess using ACVPU A= Alert 🚨 C= newly Confused 🤷♀️ V= responds to Vocal Stimuli P = responds to painful 😣 stimuli U = Unressponsive
An assessment of blood 🩸 glucose levels will be done also
ABCDE Assessment of Asthma
In an asthma attack what would expect to observe during a disability assessment?
- impaired level of consciousness due to a lack of O2 to the brain
- Really high blood 🩸 glucose levels —> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood 🩸glucose to rise
- Really low blood 🩸 glucose levels —> when you run out of Glycogen (the glucose store) blood 🩸 sugar levels will fall rapidly.
ABCDE Assessment of asthma
How do you conduct an exposure assessment in asthma?
- Full exposure is required.
- Respect ✊ of patients dignity
- Minimise heat loss
- Assess for rashes, fractures, bleeding 🩸, swelling
- Assess for allergic reaction
ABCDE Assessment of Asthma
In an asthma attack what would you expect to observe in an exposure assessment?
- You would observe cyanosis.
- Potential allergic reaction.
ABCDE Assessment for Pneumonia
What is the first step of an ABCDE assessment for Pneumonia.
- Assess the area for safety
- Early call for help
- Appropriate PPE
- Maintain dignity
ABCDE Assessment for Pneumonia
How do you conduct the Airway assessment for Pneumonia
Look, Listen, and Feel approach..
Look —> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood 🩸, vomit 🤮 or other foreign bodies in the mouth. Assess presence of swelling and colour.
Listen —> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.
Feel—> For airflow at the mouth 👄 or nose 👃
ABCDE Assessment for Pneumonia
What would you expect to observe conducting an airway assessment on someone with pneumonia?
- Cyanosis - Lack of oxygen reaching the cardiovascular 🫀 system. Due the alveoli being blocked with fluid.
- Green sputum. Caused by iron released from white blood cells with a free radical of O2 that has caused the cell to rupture.
ABCDE Assessment For Pneumonia
How do you conduct a breathing assessment for pneumonia?
Look, Listen, Feel approach.
Look —> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips 👄 and tongue 👅. Ability to hold a conversation. Position of the trachea.
Listen —> Ability to cough 😷, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.
Feel —> Chest Movement
ABCDE Assessment for Pneumonia.
What would you expect to observe conducting a breathing assessment on someone with pneumonia
- Respiratory distress due to acidosis
- Fast resp rate to try and reduce the lactate levels and raise the Ph
- Use of accessory muscles
- Breathlessness
- Rhales
Please explain these in more detail in the exam
ABCDE Assessment for Pneumonia
How do you conduct a circulation assessment for Pneumonia?
Can be done by working your way either up or down an arm
- Assess Heart ❤️ rate, rhythm 🎶, and amplitude
- Assess BP ( if low possible bleeding)
- Assess colour of hands + fingers (cyanosis)
- Assess limb 🦵 temperature 🤒
- Assess capillary refill time
- Consider urine output ( if BP is low urine out put will be low)
- nausea or vomiting 🤮 ? ( low BP can cause vomiting 🤮 and nausea)
ABCDE Assessment for Pneumonia.
What would you expose to observe when conducting a circulation assessment on someone with pneumonia?
- Expect them to be cardiovascular 🫀 unstable due to a lack of O2
- I would expect them to have a low BP due to the lack of O2 effecting the function of the heart
- Due to the low BP I would expect them to have a low urine output
- cyanosis of the extremities such as the fingers or toes.
- if the patient is frightened I would expose the them to have a fast heart rate due to the adrenaline
ABCDE Assessment for Pneumonia
How do you conduct a disability assessment for pneumonia
Assess using ACVPU A= Alert 🚨 C= newly Confused 🤷♀️ V= responds to Vocal Stimuli P = responds to painful 😣 stimuli U = Unressponsive
An assessment of blood 🩸 glucose levels will be done also
ABCDE Assessment pneumonia.
What would you expect to observe in a disability assessment on someone with pneumonia?
- Hypoxic confusion
- Impaired level of consciousness due to a lack of O2 to the brain due to the alveoli sacs being filled with fluid.
- Really high blood 🩸 glucose levels —> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood 🩸glucose to rise
- Really low blood 🩸 glucose levels —> when you run out of Glycogen (the glucose store) blood 🩸 sugar levels will fall rapidly.
ABCDE Assessment for Pneumonia
How do you conduct an exposure assessment for Pneumonia?
- Full exposure is required.
- Respect ✊ of patients dignity
- Minimise heat loss
- Assess for rashes, fractures, bleeding 🩸, swelling
- Assess for allergic reaction
ABCDE Assessment for Pneumonia
What would you expect to observe when conducting an exposure assessment on someone with pneumonia?
- Hot to touch. Due to them having a temperature
Explain in more detail for the exam
ABCDE Assessment for anaphylaxis
How do you conduct an airway assessment for Anaphylaxis
Look, Listen, and Feel approach..
Look —> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood 🩸, vomit 🤮 or other foreign bodies in the mouth. Assess presence of swelling and colour.
Listen —> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.
Feel—> For airflow at the mouth 👄 or nose 👃
ABCDE Assessment for Anaphylaxis
What would you expect to observe when conducting an airway assessment on someone experiencing anaphylaxis
- Orbital swelling ( swelling around the 👀)
- Upper air way obstruction from angioedema of the tongue 👅, pharynx, larynx, Bronchospasm.
- Chest tightness
- Cough/ wheezing
- Rhinitis
- sneezing 🤧/ congestion
- Patient has difficulty breathing and swallowing. Throat feeling like it is closing up.
- Hoarse voice
- Stridor ( that is high pitched)caused by upper airway obstruction
ABCDE Assessment for Anaphylaxis
How do you conduct a breathing assessment for anaphylaxis
Look, Listen, Feel approach.
Look —> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips 👄 and tongue 👅. Ability to hold a conversation. Position of the trachea.
Listen —> Ability to cough 😷, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.
Feel —> Chest Movement
ABCDE Assessment for Anaphylaxis
What would you expect to observe when conducting a breathing assessment on someone experiencing anaphylaxis?
- Shortness of breath/ increased resp rate
- Wheeze
- Patient becoming tired😴
- Confusion caused by hypoxia
- Cyanosis (usually a late sign)
- Respiratory arrest
ABCDE Assessment for Anaphylaxis
How do you conduct a circulation assessment for anaphylaxis?
Can be done by working your way either up or down an arm
- Assess Heart ❤️ rate, rhythm 🎶, and amplitude
- Assess BP ( if low possible bleeding)
- Assess colour of hands + fingers (cyanosis)
- Assess limb 🦵 temperature 🤒
- Assess capillary refill time
- Consider urine output ( if BP is low urine out put will be low)
- nausea or vomiting 🤮 ? ( low BP can cause vomiting 🤮 and nausea)
ABCDE Assessment for Anaphylaxis
What would you expect to observe in a circulation assessment on someone experiencing anaphylaxis?
- Faintness, Hypotension, arrhythmia, hypvolemic shock.
- Chest pain.
- Signs of shock ( pale/ clammy)
- Increased heart rate
- Low BP causing the Faint/ dizzy feeling
- Decreased consciousness or loss of consciousness
- Cardiac arrest.
ABCDE Assessment for Anaphylaxis
How do you conduct a disability assessment for anaphylaxis?
Assess using ACVPU A= Alert 🚨 C= newly Confused 🤷♀️ V= responds to Vocal Stimuli P = responds to painful 😣 stimuli U = Unressponsive
An assessment of blood 🩸 glucose levels will be done also
ABCDE Assessment for Anaphylaxis
What would you expect to see when you conduct a disability assessment on someone experiencing anaphylaxis?
- Initial reaction may be loss of consciousness
- Patient may describe ‘a sense of doom’
- Patient may become confused or agitated
- Can experience gastrointestinal symptoms
- Lack of perfusion to the CNS and the GI tract manifests as confusion, nausea.
ABCDE Assessment for Anaphylaxis
How do you conduct an exposure assessment for anaphylaxis?
- Full exposure is required.
- Respect ✊ of patients dignity
- Minimise heat loss
- Assess for rashes, fractures, bleeding 🩸, swelling
- Assess for allergic reaction
ABCDE Assessment for Anaphylaxis
What would you expect to observe when conducting an exposure assessment on someone experiencing anaphylaxis?
- Skin / mucosal changes ( this is the first feature and present in over 80% of anaphylactic reactions)
- May be erythema ( a patchy or generalised red rash)
- Cirticaria ( hives)
- Angioedema - swelling of the deeper tissues, most common in the eyelids, lips and sometimes in the mouth and throat.
ABCDE Assessment for Renal dysfunction
How do you conduct and airway assessment for Renal Dysfunction?
Look, Listen, and Feel approach..
Look —> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood 🩸, vomit 🤮 or other foreign bodies in the mouth. Assess presence of swelling and colour.
Listen —> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.
ABCDE Assessment for Renal dysfunction
What would you expect to observe when conducting an airway assessment for renal dysfunction?
- Increased resp rate - due to phrenic nerve stimulation and acidosis
- Nausea/ vomit - blood redirected to major organs reducing Gi tract activity
ABCDE Assessment for Renal dysfunction
How do you conduct a breathing assessment for Renal Dysfunction?
-Look, Listen, Feel approach.
Look —> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips 👄 and tongue 👅. Ability to hold a conversation. Position of the trachea.
Listen —> Ability to cough 😷, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.
Feel —> Chest Movement
ABCDE Assessment for Renal dysfunction
What would you expect to observe when conducting a breathing assessment for renal dysfunction?
- Increased resp rate due to acidosis
- Nausea, Vomit may be present
ABCDE Assessment for Renal dysfunction
How do you conduct a circulation assessment for renal dysfunction?
- Can be done by working your way either up or down an arm
- Assess Heart ❤️ rate, rhythm 🎶, and amplitude
- Assess BP ( if low possible bleeding)
- Assess colour of hands + fingers (cyanosis)
- Assess limb 🦵 temperature 🤒
- Assess capillary refill time
- Consider urine output ( if BP is low urine out put will be low)
- nausea or vomiting 🤮 ? ( low BP can cause vomiting 🤮 and nausea)
ABCDE Assessment for Renal dysfunction
what would you expect to observe when conducting a circulation assessment for Renal dysfunction
- Limbs will be cold due to poor perfusion
- Low or decreased BP due to cardiovascular collapse
- Vomit this can be caused by Low BP
- Decreased urine output caused by poor perfusion.
ABCDE Assessment for Renal dysfunction
How do you conduct a disability assessment for renal dysfunction?
Assess using ACVPU A= Alert 🚨 C= newly Confused 🤷♀️ V= responds to Vocal Stimuli P = responds to painful 😣 stimuli U = Unressponsive
An assessment of blood 🩸
ABCDE Assessment for Renal dysfunction
What would you expect to observe during a disability assessment?
- Altered level of consciousness - Hypoxia
- Increased heart rate - due to the release of adrenaline
- Really high blood 🩸 glucose levels —> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood 🩸glucose to rise
- Really low blood 🩸 glucose levels —> when you run out of Glycogen (the glucose store) blood 🩸 sugar levels will fall rapidly.
ABCDE Assessment for Renal dysfunction
How do you conduct an exposure assessment for renal dysfunction?
- Full exposure is required.
- Respect ✊ of patients dignity
- Minimise heat loss
- Assess for rashes, fractures, bleeding 🩸, swelling
- Assess for allergic reaction
ABCDE Assessment for Renal dysfunction
What would you expect to observe when conducting an exposure assessment for Renal dysfunction?
- Vomit
- poor urine output
- cyanosis
ABCDE Assessment Seizure and epilepsy
How do you conduct an airway assessment for seizure and epilepsy?
Look, Listen, and Feel approach..
Look —> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood 🩸, vomit 🤮 or other foreign bodies in the mouth. Assess presence of swelling and colour.
Listen —> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.
ABCDE Assessment Seizure and epilepsy
What would you expect to observe during an airway assessment in seizure and epilepsy?
- Airway occlusion, tongue thrusting/ biting excessive salivar
- During convulsions we try to ensure the patient is not at risk from I’m just but make no attempt to put anything in their mouth or between teeth
- Attempting to insert and oropharyngeal airway or other airway while the patient is actively fitting is to be avoided
ABCDE Assessment Seizure and epilepsy
How to conduct a breathing assessment for seizure and epilepsy?
- Look, Listen, Feel approach.
Look —> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips 👄 and tongue 👅. Ability to hold a conversation. Position of the trachea.
Listen —> Ability to cough 😷, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.
Feel —> Chest Movement
ABCDE Assessment Seizure and epilepsy
what would you expect to observe when conducting a breathing assessment in seizure and epilepsy?
- Respiratory distress
- Shortness of breath/ increased resp rate or apnoea
- Confusion/ cyanosis
Give high flow O2
ABCDE Assessment Seizure and epilepsy
How do you conduct a circulation assessment for seizure and epilepsy?
- Can be done by working your way either up or down an arm
- Assess Heart ❤️ rate, rhythm 🎶, and amplitude
- Assess BP ( if low possible bleeding)
- Assess colour of hands + fingers (cyanosis)
- Assess limb 🦵 temperature 🤒
- Assess capillary refill time
- Consider urine output ( if BP is low urine out put will be low)
- nausea or vomiting 🤮 ? ( low BP can cause vomiting 🤮 and nausea)
ABCDE Assessment Seizure and epilepsy
What would you expect to observe when conducting a circulation assessment in seizure and epilepsy?
- Cardiovascular instability due to hypoxia
- Decreased consciousness
- Bladder/ Bowel incontinence
ABCDE Assessment Seizure and epilepsy
How do you conduct a disability assessment in seizure and epilepsy?
-Assess using ACVPU A= Alert 🚨 C= newly Confused 🤷♀️ V= responds to Vocal Stimuli P = responds to painful 😣 stimuli U = Unressponsive
An assessment of blood 🩸glucose
ABCDE Assessment Seizure and epilepsy
What would you expect to observe when conducting a disability assessment in seizure and epilepsy?
- Altered level of consciousness
- Abnormal limb movements and eye movements
- Gastrointestinal symptoms
Check blood glucose - HYPOGLYCAEMIA
ABCDE Assessment Seizure and epilepsy
How do you conduct an exposure assessment in seizure and epilepsy?
- Full exposure is required.
- Respect ✊ of patients dignity
- Minimise heat loss
- Assess for rashes, fractures, bleeding 🩸, swelling
- Assess for allergic reaction
ABCDE Assessment Seizure and epilepsy
What would you expect to observe during an exposure assessment in seizure and epilepsy?
Reasses for fractures, bleeding and rashes that may have been obtained during the seaizure
