ITU ABCDE assessment

Question 1

Airway

Answer 1

Are they able to speak in full sentences? Self-ventilating
Type of airway: ETT, trachy, NPA, OPA
Size/length/secured with. Cuff pressure

Question 2

Breathing

Answer 2

Non-invasive ventilation: FM, NS, HFNO, CPAP, BiPAP- type of mask
Invasive ventilation: PC (Bi-level), PS (SPONT), CPAP, SIMV
RR, tidal volumes, LPV aims, FiO2 or L/min, EtCO2, SpO2
Physio: cough, deep breathing exercises, Spiro-Ball, suction, secretions, nebulisers
Auscultate chest: air entry, secretions, wheeze, stridor
Chest drains: output, colour, swinging, bubbling, low suction

Question 3

Circulation

Answer 3

BP, HR, heart rhythm, CVP
CVS supported or unsupported? Inotropes/antihypertensives
Cardiac output monitoring (LiDCO or Swan-Ganz catheter)
CRT (central and peripheral)
12-lead ECG
CVVH (aims and settings)
Intake: oral intake, IV fluids, IV infusions
Output: UO, bowel movements, drain output

Question 4

Disability

Answer 4

Sedated/not sedated? GCS, pupils, limb power, RASS, CAM-ICU
Blood glucose: Actrapid scale, SC insulin, glucose infusion
Electrolytes: K, Na, Ca, Mg, PO4-
Pain assessment: PCA, epidural, pain busters, oral/IV analgesia

Question 5

Exposure

Answer 5

Full skin assessment: pressure ulcers, moisture damage, friction damage, rashes, burns, surgical wounds
Nutrition: NBM, NG, NJ, PEG, JEJ, Ryles, TPN
Temperature: Bair Hugger, Arctic Sun
IV lines: CVC, Vascath, Swan-Ganz, A-line, PVC and VIP scores
TEDS/Flowtrons

Question 6

Other

Answer 6

NOK details (name, relation and number)
Await ward round: flag up issues, make suggestions for plan of care
MRSA/COVID/CPE swabs
Blood/urine/stool/sputum cultures