ABCDE Assessment
- Created by: MillieJohnson2004
- Created on: 06-10-22 15:30
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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
- If there is an obstruction ask patient to cough if that does not work suction
- Gurgling may mean there is a partial obstruction in the airway
- 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
- Airway
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