ABCDE Assessment

-systematic framework

- ABCDE assessment permits the identification of patient problems by order of severity enabling suitable interventions to be delivered according to clinical priority and patient need

-Assess the airway

-ask an open question and take note of the patients abilty to answer

-is airway patent?

-if talking then airway is patent

-if not patent : head tilt chin lift

-listen for any abnormal sounds (obstruction)

- obstruction is life threatening so assessing airway allows for identificaton of this

-asking question allows you to build an initial rapport with patient and gain insight 

-Assess rate, rhythm + effcacy of breathing

-Measure SPO2 

-Resp rate for a full minute (resp rate is early indicator of deteriorating patient)

-Look at chest for equal rise and fall in both sides

-Listen for sounds during breathing (breathing is usually quiet)

-Look for use of accessory muscles (this indicates diffculty breathing)

-Measure and record patients blood pressure

-Measure and record pulse rate 

-Capillary refill time (if below 2secs indicates adqueate peripheral perfusion)

-reduced peripheral perfusion is seen in patients with shock

-Assess fluid status of patient

-skin, tongue and mucous membranes for signs of dehydration

-review fluid balance if has one

-test urine (colour, amount)

-Conscious level (AVPCU)

-Consider more in depth assessment of conscious level (GCS + pupilary light)

-Ask if patient is in pain

- PQRST: Provoking/Palliating factors (What brought on the pain? What were you doing when the pain started? What measures have helped relieve the pain?); Quality (Can you describe your pain in your own words? What does it feel like?); Radiation (Can you show me where the pain is? Do you have pain anywhere else?); Severity (On a scale of 0 (no pain) to 10 (worst pain ever experienced), how would you rate your pain?); Timing (How long did it last?)

-Blood glucose testing

-Review patients medications

-Look for other signs

-Temperature 

-Inspect skin for any rashes, wounds etc

-Medical devices

-Observe for signs of blood loss

-Assess abdominal area (pain, bleeding, distention)

-Report finding according to NEWS2 escalation guidance using a structured communication tool e.g., Introduction, Situation, Background, Assessment, Recommendation, Decision.  

- Track + trigger using NEWS2

-Escalate to DR for review regarding anything abnormal

-Consider pain relief

-Fluids needed?