ABCDE Assessment

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  • ABCDE assessment
    • Airway
      • Check if clear; tilt head by holding chin and forehead
      • Is there a response?
        • If there is a response move onto Breathing
        • If there is not a response is there any sounds such as gurgling
          • Gurgling may mean there is a partial obstruction in the airway
            • If there is an obstruction ask patient to cough if that does not work suction
              • Zig-Zag motion for suction; pressure at 100-120 (Changes due to hospital policy
    • Breathing
      • Breaths per minute (12-20)
      • Rhythm: is the rhythm regular or irregular?
      • Volume: Is the volume shallow or deep?
      • Look, Listen, Feel
        • Look: Symmetry? Pneumothroax? colour of the patient? Is the patient cyanosed
        • Listen: Stethoscope. Is there a wheeze? Crackling sound? No sound? Bubble sound?
        • Feel: Does the chest feel uneven
    • Circulation
      • Blood pressure (100-140) systolic (60-90) diastolic
      • Heart rate: 60-100
      • Capillary refill time less of equal to 2 seconds. Can check about finger or chest
      • Tempreture (36-37.5)
      • Urine output 0.5/1ml/kg/hr
        • could signify a lack of Kidney function leading to shock
      • Blood function
        • Full blood count
        • U&E and LFT (Brown bottle)
        • Congulation blood
        • CRP- C-Reactive protien test for infection
    • Disability
      • Alert, Voice, Pain, Unresponsive, New confusion
      • Glasgow Coma Scale (maximum 15 (good)) (minimum 3 (bad))
        • Eyes(4) Verbal(5) Motor(6)
        • PEARL: pupils, size and reactive
      • Drugs? have any drugs they have taken affected the patient?
      • Blood sugars: Hypo? Hyper? (Diabetes UK)
    • Exposure
      • Head to toe assessment of patient
      • Rash, Bruises, Pressure sores, PMH, Pain score


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