For the last couple of weeks, I have been reading in preparation for my Acute Illness Management course (Greater Manchester Critical Care Skills Institute, 2014). I have covered chapters on caring for acutely ill patients who have respiratory problems, hypotension, severe sepsis, a poor urine output, an altered level of consciousness and acute pain. As well as learning about the specifics of each condition, a common systematic assessment method of ABCDE was applied to each. Acute illness management is extremely important, because, historically, there have been failures in measuring and recording basic routine observations, in recognising when vital signs get worse, and therefore a delay in responding to deteriorating patients appropriately and timely (National Patient Safety Agency, 2007).
Yesterday, I attended a series of lectures and workshops which related to each of the above conditions and the assessment process in more detail. An assessment demonstration of a patient was given, followed by a chance to practise, and watch others practising assessment. Finally, I was individually assessed in carrying out an ABCDE assessment on an acutely ill ‘patient’ mannequin, and also had to take a written test too. The practical test was extremely nerve-wracking and there was a lot to remember, but fortunately for me, I was able to pass on both of the elements. Hereby follows an overview of what an ABCDE assessment involves, in order for me to reflect upon and consolidate my learning.
Initially, wherever possible, information on the patient’s situation and background must be handed over to the assessing nurse. This should include their name, age, what has currently happened to them, and a brief overview of their medical history, including known drug allergies, and previous diagnoses.
AIRWAY: A patient’s airway MUST be patent and maintained before anything else can be done – if the patient cannot get oxygen into their body, they will soon die from hypoxia. An easy way to check the airway is to speak to the patient, and if they can talk back this is a positive sign. Thinking about the patient in terms of AVPU – Alert, Voice, Pain or Unresponsive – if the person is in the Pain or Unresponsive stage, their airway is likely to need some assistance, such as an oropharyngeal airway, and may also benefit from repositioning onto their side.
Alternatively, the patient may have an obstruction in their mouth and may require some suction. If there are any noises, such as snoring, crowing, gurgling or stridors, these are likely indicators of an obstruction, while a crackling noise may indicate pulmonary oedema (fluid on the lung). If a patient has pulmonary oedema, it is important not to give them fluids, as they may drown internally. A see saw chest and abdomen movement, where the chest moves inwards and the stomach moves out, is likely to indicate a complete airway obstruction.
Once the airway is patent, the patient may require some breathing assistance, and so their oxygen saturations should be checked to determine their O2 levels. A 15 litres per minute non-rebreather high concentration oxygen mask should be applied, if required. The bag should be inflated by two-thirds before putting onto patient. Normal O2 levels are 94-98%, or 88-92% for a person with Chronic Obstructive Pulmonary Disease.
BREATHING: Once the airway has been properly attended to, the breathing can now be assessed. Look at the depth, rate and rhythm of the breathing. Is the respiration in the normal range of 12-20 per minute? Or is it raised or decreased? An increased respiratory rate is an early indicator of deterioration, and the patient will soon get tired from continued tachypnoea. Look for symmetry in the chest movement. Is the patient struggling to breath and having to use accessory muscles, such as the shoulders? Consider sitting the patient upright with pillows, as it will be more difficult for them to breath when lying flat on their back. Look at the patient’s colour, and determine whether it is healthy, pale or cyanosed. A good indicator of central cyanosis is a blue-tinged tongue, or blueness inside of the lips. If oxygen has not already been considered, now is an opportunity to determine the oxygen saturations, and to apply a 15 litres per minute high concentration oxygen mask, if required.
CIRCULATION: Once the breathing has been addressed, the circulation can now be assessed. Starting at the tips of the fingers, check the capillary refill time by depressing the finger tip for 5 seconds. Does the blood return at a normal rate of about 2 seconds, or is it increased or decreased? Moving on to the radial pulse (on the wrist), is it in the normal range of about 80-100, or is it raised or slow? Is the heart rate strong and bounding, or is it weak and thready? Moving up the arm, is there a wide bore cannula in situ and patent, or does that need to be attended to later? Does the manual blood pressure fall within the normal range? 120/80 mmHg is ideal, but anything between 90/60 mmHg to 140/90 mmHg may be acceptable (NHS Choices, 2015). If a patient has baseline measurements, these are really useful for making informed comparisons of what is normal for them. Do not use electronic dynamap machines when patients are acutely unwell, as they are likely to be inaccurate or will result in an error message.
Moving up to the underarm (axillary), is the patient’s temperature normal, pyrexic or low? This should ideally be about 36.5˚C. Moving across and down to the stomach area, consider whether the patient has a normal urine output, or is there no information on this? A normal output is about 0.5 ml/kg/per hour, so should therefore be about 35 ml for a 70 kg patient. Consider putting the patient onto a fluid balance chart for monitoring. If the heart rate is higher than the blood pressure, consider giving fluids to rectify the readings. 250 ml of 0.9% sodium chloride IV over 5-10 minutes is standard. Once the fluid is administered, any changes in pulse and blood pressure should be reassessed, and then another 250 ml can be given, if necessary. Once all the circulation checks are complete, bloods can be taken from the cannula site, and should generally include a Full Blood Count, Urea and Electrolytes, INR for clotting and Glucose. If the patient has a high temperature, blood cultures should be taken to check for sepsis infection, and in the case of sepsis, IV antibiotics would need to be administered too. Once the bloods are obtained, the IV fluid or antibiotics can then be administered via the site.
*****Throughout the whole assessment process, it is important to keep going back to check on the previous stages. For example, if an oropharyngeal airway was used in an unconscious patient to maintain the airway, and the patient becomes conscious, the airway adjunct will need to be removed. If the patient is using an oxygen mask however, this should be kept on until the doctor arrives; although oxygen saturations should be periodically checked.
DISABILITY: An excellent mnemonic to remember this stage is GAPPS. G – Glucose – does the patient have normal blood glucose readings between 4-7 mmol/l, or are they presenting as hypo or hyper-glycaemic? If hypoglycaemic, IV dextrose will be required. If hyperglycaemic, insulin will be required, although this would need prescribing by a doctor. A is AVPU – Alert, Voice, Pain, Unresponsive – how is the patient doing? Are there any improvements?
P – Pupils – when a light is shined in a sweeping moment across each eye, do the pupils constrict ordinarily in reaction to the light, or are they dilated and possibly indicative of drugs? Does one pupil constrict and the other dilate? Unilateral responses could be a sign of neurological injury (Patient, 2015).
P is also for pain. Is there any indication of pain in the patient? If so, a doctor will need to prescribe an appropriate level of pain relief. Finally, S is for seizures. Has the patient had any seizures? If they are prolonged or recurrent, the usual treatment is rectal diazepam (Epilepsy Action, 2015).
EXPOSURE: The physical assessment concludes with a head to toe examination of the patient, front and back, in order to ensure that nothing abnormal has been missed, such as wounds/trauma, rashes, swelling or dryness. Once this is finished, it is important to go back to the earlier stages again, and make sure that everything is stable or improving.
Once the doctor arrives, it is essential that the assessing nurse hands over the full information of what has been done, including the patient’s initial presentation and background, the assessment findings, and any actions taken. The nurse needs to ask the doctor for a management plan and also for further prescriptions of oxygen, fluid, pain relief, insulin, etc. A useful tool for communicating information accurately is the SBAR model – Situation, Background, Assessment and Recommendations.
References and Further Reading
Epilepsy Action. (2015). Status epilepticus. Retrieved 21st November, 2015, from https://www.epilepsy.org.uk/info/treatment/status-epilepticus
Greater Manchester Critical Care Skills Institute. (2014). Acute Illness Management (5th ed.). Greater Manchester: Critical Care Skills Institute.
National Patient Safety Agency. (2007). Safer care for the acutely ill patient: learning from serious incidents. Retrieved from http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59828
NHS Choices. (2015). Your NHS health check results. Retrieved 21st November, 2015, from http://www.nhs.uk/Conditions/nhs-health-check/Pages/Understanding-your-NHS-Health-Check-results.aspx
Patient. (2015). Pupillary abnormalities. Retrieved 21st November, 2015, from http://patient.info/doctor/pupillary-abnormalities