ABCDE OSCE Assessment for nurses

The approach should remain consistent when dealing with patients who are deteriorating or critically ill. There are fundamental principles that guide this approach.

• Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient. 
• It is essential to conduct a thorough initial assessment and regularly re-assess.
• Address life-threatening problems before progressing further with the assessment.
• Assess the effects of treatment. 
• Recognise when you need extra assistance and seek appropriate help early.
• Use all members of the team. This allows interventions simultaneously. 
• Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR) or Reason, Story, Vital signs, Plan (RSVP) approach. 
• The first goal of treatment is to keep the patient alive allowing for more time to diagnose and provide additional treatment.

• Ensure personal safety. Wear an apron and gloves as appropriate. 
• First, look at the patient, in general, to see if the patient appears unwell. 
• If the patient is awake, ask, “How are you?” If the patient appears unconscious or has collapsed, shake him and ask, “Are you alright?” If he usually responds, he has a patent airway, is breathing and has brain perfusion. If he speaks only in short sentences, he may have breathing problems. Failure of the patient to respond is a clear marker of critical illness. 
• This first rapid " Look, Listen and Feel” of the patient should take about 30 s and will often indicate a patient is critically ill and needs urgent help. Ask a colleague to ensure appropriate help is coming.
• Monitor the vital signs early. Attach a pulse oximeter, ECG monitor and a non-invasive blood pressure monitor to all critically ill patients as soon as possible. 

• Wash your hands and consider PPE when appropriate.
• Respect patient privacy and dignity and ask for consent.
• Remember bedside checks (for instance, is there functioning suction and oxygen?).

INTRODUCE YOURSELF and explain what you are there to do

"Good morning, my name is Anton, Can you confirm your name and date of birth, please?

Can I call you ... (check their preferred name).

I have been asked to do a full ABCDE assessment on you, which consists of assessing your Airways, Breathing, Blood pressure, pulse and a full head to toe check of your body. Are you happy with me to proceed?" (always ask for consent)

Airway obstruction is an emergency. Get expert help immediately. 

Look for signs of airway obstruction.

• Airway obstruction causes paradoxical chest and abdominal movements (‘see-saw’ respirations) and the use of the accessory muscles of respiration. There are no breath sounds at the mouth or nose in complete airway obstruction. In partial obstruction, air entry is diminished and often noisy. Central cyanosis is a late sign of airway obstruction. 
• In the critically ill patient, depressed consciousness often leads to airway obstruction. 

Treat airway obstruction as a medical emergency.

• Obtain expert help immediately. Untreated airway obstruction causes hypoxaemia (low PaO2) with the risk of hypoxic injury to the brain, kidneys & heart, cardiac arrest, and death. 
• In most cases, only simple methods of airway clearance are required (e.g. airway opening manoeuvres, airways suction, and insertion of an oropharyngeal or nasopharyngeal airway). Tracheal intubation may be necessary when these fail. 

When there are no obstructions, we say AIRWAY IS PATENT.

• Look, listen and feel for the general signs of respiratory distress: sweating, central cyanosis, use of the accessory muscles of respiration,abdominal breathing. 
• Count the respiratory rate. A high (> 25 min-1) or increasing respiratory rate is a marker of illness and a warning that the patient may deteriorate suddenly. The normal rate is 12–20 breaths min-1. 
• Assess the depth of each breath, rhythm, and chest expansion equal on both sides. A chest deformity may increase the risk of deterioration.
• Record SpO2 reading of the pulse oximeter. 
• Listen to the patient’s breath sounds: rattling airway noises indicate presence of secretions. Stridor or wheeze suggests partial but significant airway obstruction. 
• Percuss the chest: hyper-resonance may suggest a pneumothorax; dullness usually indicates consolidation or pleural fluid. 
• Auscultate the chest: bronchial breathing indicates lung consolidation with patent airways; absent or reduced sounds suggest a pneumothorax, pleural fluid...
• Check the position of the trachea in the suprasternal notch: deviation to one side indicates mediastinal shift (e.g. pneumothorax, lung fibrosis or pleural fluid). 

• Look at the colour of the hands and digits: are they blue, pink, pale or mottled? 
• Assess the limb temperature by feeling the patient’s hands: cool or warm? 
• Measure the capillary refill time (CRT). The normal value for CRT is usually < 2 s.
• Count the patient’s pulse rate (count for 1 minute).
• Measure the patient’s blood pressure. 
• Auscultate the heart. Is there a murmur or pericardial rub? Are the heart sounds difficult to hear? Does the audible heart rate correspond to the pulse rate? 
• Look for other signs of poor cardiac output, such as reduced consciousness and urine output.
• Insert one or more large (14 or 16 G) intravenous cannulae. 
• Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological investigations and cross-matching before infusing intravenous fluid. 
• If the patient has primary chest pain and a suspected ACS, record a 12-lead ECG. 

• Examine the pupils (size, equality and reaction to light). 
• Make a rapid initial assessment of the patient’s conscious level using the AVPU method: Alert, responds to Vocal stimuli, responds to Painful stimuli or Unresponsive to all stimuli. Alternatively, use the Glasgow Coma Scale score. A painful stimuli can be given by applying supra-orbital pressure (at the supraorbital notch). 
• Measure the blood glucose to exclude hypoglycaemia using a rapid bedside testing method.

• Check body temperature
• To examine the patient properly full exposure of the body may be necessary. Respect the patient’s dignity and minimise heat loss. 

• Take a complete clinical history from the patient, relatives, friends, and other staff. 
• Review the patient’s notes and charts.
• Study both absolute and trended values of vital signs. 
• Check that important routine medication are prescribed and being given. 
• Calculate the NEWS2 score and complete entries in the patient’s notes of your findings, assessment and treatment. Where necessary, escalate the patient to your colleagues (doctors, senior nurses etc.)
• Record the patient’s response to therapy. 
• Consider definitive treatment of the patient’s underlying condition.