ABCDE Assessment, NEWS chart and SBAR Handover

Question 1

When do we use an ABCDE assessment and why?

Answer 1

• Use on any patient who is acutely unwell or deteriorating
• Gives a baseline physiology of that patient
• Useful to handover to other colleagues (paramedics etc)

Question 2

Facts about ABCDE

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Answer 2

• Assessed in order of importance
• Do not move onto next stage before you have completed and sorted the current stage (Assess, Address, Advance)
• Go back to A if things change, always reassess

Question 3

What is important when assessing your patient prior to patient becoming unwell?

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Answer 3

• Make sure you know their medical history
• Check they have emergency meds with them (salbutamol inhaler, GTN spray)
• If they don’t make sure you know where the emergency drug box is

Question 4

What does A stand for?

How do we know if it is ok or not?

How do we fix it if it is occluded?

Answer 4

Airway

If patient is talking, the airway is clear, if breathing is noisy, then airway is likely obstructed

Airway opening manoeuvers - head tilt and chin lift, with or without a jaw thrust. If patient is unconscious, insert airway adjunct, ventilate with bag valve mask and high flow oxygen via rebreather bag

Question 5

What does B stand for?

How do we assess this?

What is normal respiratory rate? At what rate raises great concern?

What is normal O₂ saturation?

Answer 5

Breathing

• look, listen and feel: count respiratory rate and effort, look at colour, listen for wheeze/not being able to finish sentences

Normal respiratory rate: 12-20 breaths per minute, below 8bpm is very concerning

Normal 0₂ saturation: 96% and above

If person is unresponsive and not breathing, start CPR!

Question 6

What does C stand for?

What do you assess?

What are the normal values for these assessments?

Answer 6

Circulation

• Heart rate (60-100bpm is normal)
• Blood pressure (systolic 110-140mmHg is normal)
• Capillary refill time (~2 seconds or less): least reliable, should only be used as a guide

Question 7

What does D stand for?

What should you check for?

Name the scale/acronym used in this stage:

Answer 7

Disability

Important if patient is diabetic to check blood glucose levels

• ACVPU scale:
• Alert
• Confusion (new)
• responds to Voice
• responds to Pain
• Unresponsive

FAST: Face, Arm, Speech, Telephone in case of acute stroke

Question 8

What does E stand for?

What should be checked here?

Answer 8

Exposure

• Temperature (> 38.0 can be a marker for sepsis)
• Any rashes

Question 9

How do you keep a record of an ABCDE assessment?

What does this chart show?

When is this chart not used?

Answer 9

By using a National Early Warning Score (NEWS) chart

• A record of physiology and stability of the patient
• Standardises the assessment of all acutely ill patients
• A deteriorating NEWS score is a sign of decreasing physiological stability

A NEWS chart is not suitable for children under 16 and in pregnancy as physiology is so altered.

Question 10

Explain the different types of NEWS score and what they mean:

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Answer 10

• Low: 1-4 - nurse review in hospital
• Medium: 5-6 OR a single RED score - urgent review by skilled clinician
• High: 7 or more - emergency review by clinical team

Question 11

After completing ABCDE assessment, what should you use to handover to colleagues?

Give a brief description of each step:

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Answer 11

You should hand over patient using SBAR:

• Situation: Introduce yourself, summarise main problem
• Background: relevant positive and negative findings in medical and dental history, sequence of events
• Assessment: what observations are, NEWS score, what diagnosis you think
• Recommendation: communicate clearly what you would like from the other clinician