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A to E Assessment
NURSING PRACTICE MODULE YEAR 1 (NUR1020)
University of Surrey
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A to E Assessment
The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a systematic approach which is used to carry out an immediate assessment to access the condition a patient is in and the treatment of critically ill or injured patients.
- The ABCDE approach is the most recognised tool for rapid patient assessment, it allows us to recognise life-threatening conditions early and provides a systematic method that focuses on identifying problems and implementing critical interventions in a timely manner.
- A to E assessment is suitable for all age groups
- As long as we know what’s normal, we can assess and act on the abnormal
- A to E assessment is quick and most of it can be done without any equipment
Airway (Induction):
- Airways are structures that allow the normal passage of air to flow from the outside of the body (the atmosphere) to the lower respiratory tract (to the lungs to allow the change exchange of oxygen for carbon dioxide.
A – Airway (Assessment) What is normal?
Sounds: Breathing which is quiet, calm and without any abnormal noises- this suggests that the flow is normal.
Speech (age/cognitive ability appropriate): Speech or sounds which are normal for the individual, they are not finding it difficult to speak due to an obstruction.
Chest movement: Is it equal on both sides? If the chest movement is equal both sides, this would suggest that the individual’s airway to flow normal through the airway structures without any obstruction.
Effort: Are they breathing comfortably? Are they having to work hard to breathe?
B- Breathing (Assessment) What is Normal? The purpose of breathing is to keep us alive and to keep our organs functioning. Breathing involves the exchange of carbon dioxide for oxygen to adequately oxygenate the organs and maintain homeostasis. We want to take in oxygen and get rid of carbon dioxide which, if it builds up, can cause our blood to become too acidic leading to death if this isn’t corrected as the organs begin to fail.
- When we take a breath in this is called inspiration and this means that our diaphragm flattens from the usual dome shape and our external intercostal muscles contract to elevate the ribs and sternum this creates more space in the thoracic cavity. Because of Boyles Law, and the increase in volume, the pressure in the lungs goes down, this
means that the pressure of air outside of our body (atmospheric pressure) is now greater than the pressure inside our lungs. In order to this to be equalised, air rushes in through the nose and mouth and fills the lungs equalising the pressure. This inspiratory breath is filtered and warmed by the upper airway before it reaches the lungs where oxygen is caried into the blood via the alveoli.
When we breath out we are carrying away carbon dioxide. It’s the same process but in reverse – the diaphragm relaxes to its resting position and the external intercostal muscles relax to depress the ribs and sternum. This causes a decrease to the volume in the thoracic cavity and, remembering Boyle’s Law, the pressure has now increased. This means the pressure inside the lungs is greater than atmospheric pressure and air rushes out of the lungs and into the atmosphere to maintain equilibrium.
Assessment for Breathing:
Effort: How much effort are they putting in? Are they breathing at a normal rate (breaths per minute)? Is the pattern of breathing steady and even? Are there any unusual sounds?
Efficacy: Is their breathing keeping them oxygenated? Is their chest moving equally on both sides?
Effect: Is their skin colour normal especially around the mouth and nose? Is their breathing having a detrimental effect on any other part of their body? Are they alert and behaving typically?
C- Circulation Induction
The structures in the circulatory systems are the heart and blood vessels (arteries, veins and capillaries).
Heart – the function of the heart in terms of the effort it’s making to maintain healthy circulation
Vessels – blood flow through arteries, veins and capillaries.
C- Circulation Assessment:
Heart Rate: How many times does their heart beat in one minute?
Blood pressure: When you take their blood pressure, Is it at a healthy level for a child or adult of their age?
Systolic blood pressure (the first number) indicates how much pressure blood is exerting against the artery walls when the heart beats.
Skin – assessing skin is essential as it not only tells us about possible systemic illness but also allows us to assess for possible injury or past medical history such as operative scars.
What does the A to E model tell us?
- Using the A to E model allows us to structure the approach to assessment
- Starting the Airway and moving through each aspect means that the most life- threatening aspects are addressed first
- This approach allows us to make a judgment on a person’s clinical condition.
- Knowing what’s normal allows us to better assess what is not.
A to E Assessment Structure:
A- Airways B- Breathing C- Circulation D- Disability E- Exposure
Airways-
Check the individual’s airways, an obstruction in the airways is a medical emergency. If left untreated, an obstruction can cause hypoxia, hypoxia is a serious condition which is cause when not enough oxygen is able to make it to the cells and tissues in the body leading to serious and in some circumstances life threatening consequences such as problems with an individual’s heart and brain function. Signs of a potential airway obstruction include paradoxical chest and abdominal movements which can appear to move in a ‘see-saw’ motion, breathing through the mouth and nose being noisy or in severe cases of airway obstruction, no breathing sounds being heard from the individual’s nose or mouth.
Airway obstruction is a medical emergency, expert medical assistance is needed urgently. Treatment methods of airway obstruction can include airway opening manoeuvres, airways suction, insertion of an oropharyngeal or nasopharyngeal airway, these are the most common methods for treating airway obstruction however if these are unsuccessful tracheal intubation may be required in order to clear the obstruction.
Oxygen needs to be given at a high concentration, the easiest way to deliver oxygen to a patient is to use an oxygen mask with an oxygen reservoir. The oxygen flow must be high, typically this is around 15 litres of oxygen per minute in order to ensure that the oxygen reservoir works successfully and doesn’t collapse when the patient is requiring oxygen. In severe cases of airway obstruction, a person’s trachea may be intubated which will mean that they will need to be given a high concentration of oxygen with a self-inflating bag. Depending on the severity of a patient’s airway obstruction, their oxygen levels should typically be kept between 88-98%.
Acute respiratory failure (Oxygen levels 94-98%)
Hypercapnic respiratory failure (Oxygen levels 88-92%)
Breathing:
- Breathing must be observed, diagnosed and treated immediately, life-threatening conditions such as acute severe asthma, pulmonary oedema, tension pneumothorax, and massive haemothorax.
- Check for signs of respiratory distress such as an increased breathing rate, sweating, wheezing, nose flaring and abdominal breathing.
- Count the individual’s respiratory rate. The normal respiratory rate is 12-20 breaths per minute. If patient has a fast respiratory rate, this can be a sign that they are deteriorating or they may be at risk of rapidly deteriorating.
CRT suggests poor peripheral perfusion. Other factors (e. cold surroundings, poor lighting, old age) can prolong CRT. 4. Assess the state of the veins: they may be underfilled or collapsed when hypovolaemia is present. 5. Count the patient’s pulse rate (or preferably heart rate by listening to the heart with a stethoscope). 6. Palpate peripheral and central pulses, assessing for presence, rate, quality, regularity and equality. Barely palpable central pulses suggest a poor cardiac output, whilst a bounding pulse may indicate sepsis. 7. Measure the patient’s blood pressure. 8. 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? 9. Look for other signs of a poor cardiac output, such as reduced conscious level and, if the patient has a urinary catheter, oliguria (urine volume < 0 mL kg-1 h-1). 10. Look thoroughly for external haemorrhage from wounds or drains or evidence of concealed haemorrhage (e. thoracic, intra-peritoneal, retroperitoneal or into gut). Intra-thoracic, intra-abdominal or pelvic blood loss may be significant, even if drains are empty. 11. The specific treatment of cardiovascular collapse depends on the cause, but should be directed at fluid replacement, haemorrhage control and restoration of tissue perfusion. Seek the signs of conditions that are immediately life threatening (e. cardiac tamponade, massive or continuing haemorrhage, septicaemic shock), and treat them urgently. 12. Insert one or more large (14 or 16 G) intravenous cannulae. Use short, wide-bore cannula, because they enable the highest flow. 13. Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching, before infusing intravenous fluid. 14. Give a bolus of 500 mL of warmed crystalloid solution (e. Hartmann’s solution or 0% sodium chloride) over less than 15 min if the patient is hypotensive. Use smaller volumes (e. 250 mL) for patients with known cardiac failure or trauma and use closer monitoring (listen to the chest for crackles after each bolus). 15. Reassess the heart rate and BP regularly (every 5 min), aiming for the patient’s normal BP or, if this is unknown, a target > 100 mmHg systolic. 16. If the patient does not improve, repeat the fluid challenge. Seek expert help if there is a lack of response to repeated fluid boluses.
If symptoms and signs of cardiac failure (dyspnoea, increased heart rate, raised JVP, a third heart sound and pulmonary crackles on auscultation) occur, decrease the fluid infusion rate or stop the fluids altogether. Seek alternative means of improving tissue perfusion (e. inotropes or vasopressors).
If the patient has primary chest pain and a suspected ACS, record a 12-lead ECG early.
Immediate general treatment for ACS includes:
Aspirin 300 mg, orally, crushed or chewed, as soon as possible.
Nitroglycerine, as sublingual glyceryl trinitrate (tablet or spray).
Oxygen: only give oxygen if the patient’s SpO2 is less than 94% breathing air alone.
Morphine (or diamorphine) titrated intravenously to avoid sedation and respiratory depression.
Disability:
Common causes of unconsciousness include profound hypoxia, hypercapnia, cerebral hypoperfusion, or the recent administration of sedatives or analgesic drugs.
- Review and treat the ABCs: exclude or treat hypoxia and hypotension.
- Check the patient’s drug chart for reversible drug-induced causes of depressed consciousness. Give an antagonist where appropriate (e. naloxone for opioid toxicity).
- 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 finger-prick bedside testing method. In a peri-arrest patient use a venous or arterial blood sample for glucose measurement as finger prick sample glucose measurements can be unreliable in sick patients. Follow local protocols for management of hypoglycaemia. For example, if the blood sugar is less than 4 mmol L-1 in an unconscious patient, give an initial dose of 50 mL of 10% glucose solution intravenously. If necessary, give further doses of intravenous 10% glucose every minute until the patient has fully regained consciousness, or a total of 250 mL of 10% glucose has been given. Repeat blood glucose measurements to monitor the effects of treatment. If there is no improvement consider further doses of 10% glucose. Specific national guidance exists for the management of hypoglycaemia in adults with diabetes mellitus.
- Nurse unconscious patients in the lateral position if their airway is not protected.
AVPU- Records the condition which best describes the patient.
A- Alert
V- Voice
A to E Assessment
Module: NURSING PRACTICE MODULE YEAR 1 (NUR1020)
University: University of Surrey
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