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ILS Course - A to E Training & Solutions Ltd > ABCDE Assessment > Flashcards

ABCDE Assessment Flashcards

1
Q

What is the Chain of Prevention for in-hospital cardiac arrest?

A

1. Education
2. Monitoring
3. Recognition
4. Call for Help
5. Response

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2
Q

What parameters are used for NEWS2 score?

A
  1. RR
  2. Sats
  3. Air or O2
  4. SBP
  5. Pulse
  6. Consciousness
  7. Temp
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3
Q

NEWS2 Score 3 - RR:

A
  1. ≤ 8
  2. ≥ 25
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4
Q

NEWS2 Score 3 - SpO2 scale 1:

A
  1. ≤ 91%
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5
Q

NEWS2 Score 3 - SpO2 scale 2:

A
  1. ≤ 83%
  2. ≥ 97% on O2
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6
Q

NEWS2 Score 3 - SBP:

A
  1. ≤ 90
  2. ≥ 220
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7
Q

NEWS2 Score 3 - Pulse:

A
  1. ≤ 40
  2. ≥ 131
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8
Q

NEWS2 Score 3 - Consciousness:

A
  1. CVPU
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9
Q

NEWS2 Score 3 - Temperature:

A
  1. ≤ 35
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10
Q

NEWS 2 score = 1- 4

Frequency of monitoring:

Clinical response:

A

Frequency of monitoring:
1. 4-6 hourly

Clinical response:
1. Nurse to assess pt.

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11
Q

NEWS 2 score = 3 in single parameter

Frequency of monitoring:

Clinical response:

A

Frequency of monitoring:
1. Minimum 1 hourly

Clinical response:
1. Nurse to inform medical team
2. Medical team to R/V

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12
Q

NEWS 2 score = 5 or 6

Frequency of monitoring:

Clinical response:

Urgent response threshold

A

Frequency of monitoring:
1. Minimum 1 hourly

Clinical response:
1. Urgent assessment by clinician skilled in care of acutely ill pts.
2. Provide clinical care
3. Monitoring facilities

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13
Q

NEWS 2 score = ≥ 7

Frequency of monitoring:

Clinical response:

Emergency response threshold

A

Frequency of monitoring:
1. Continuous monitoring

Clinical response:
1. Nurse to immediately inform medical team at specialist registrar level
2. Emergency assessment by team with critical care skills (including advanced airway Mx)
3. T/F to HC or ICU or CCU
4. Provide clinical care
5. Monitoring facilities

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14
Q

What does ABCDE assessment stand for?

A
  1. Airway
  2. Breathing
  3. Circulation
  4. Disability
  5. Exposure
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15
Q

What are the underlying principles of A-E assessment?

A
  1. Call for help early
  2. Complete an initial assessment
  3. Rx life-threatening problems before moving onto the next part
  4. Use team members so that interventions can be done simultaneously
  5. Reassess the effects of interventions until senior help arrives
  6. Monitor vital signs early - sats, ECG, NIBP
  7. Communicate effectively
  8. Keep calm
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16
Q

What are the FIRST STEPS when considering ABCDE Approach?

A
  1. Personal safety - gown, gloves & other PPE
  2. First impression - how does the patient look?
  3. Ask “How are you?”
  4. Apply monitoring - Sats, RR, HR, BP, temp
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17
Q

What to do if pt. is unconscious, unresponsive & not breathing normally on initial assessment?

A
  1. Start CPR
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18
Q

Airway - How to quickly assess if pt’s airway is patent?

A
  1. Pt. is talking - air is able to pass through the vocal cords
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19
Q

Airway - What is the consequence of airway obstruction?

A
  1. Hypoxia
  2. Leads to cardiac arrest
20
Q

Airway - If there’s an airway obstruction, what do you do?

A
  1. Simple airway manoeuvres
21
Q

Airway - Complete Rx of airway obstruction:

A
  1. Rx problem putting airway at risk - suction secretions
  2. Turn pt. onto side
  3. Give high flow O2 - 15 L/min
  4. Simple airway manoeuvres
  5. OP or NP airway

Sats range:
94-98% normal pt.
88-92% hypercapnic resp. failure

22
Q

Breathing - How to categorise breathing probelms?

A
  1. Problems with respiratory drive - CNS depression
  2. Problems with respiratory effort - mm. weakness or nerve damage (MG, GBS, MS)
  3. Lung disorders - pneumonia, COPD, asthma, PE
23
Q

Breathing - How to recognise breathing problems?

A
  1. Look
  2. Listen
  3. Feel
24
Q

Breathing - How to recognise breathing problems - What to Look for?

A
  1. RDS
  2. RR ≥ 25
  3. Accessory mm. use
  4. Low sats
  5. Cyanosis
  6. Chest deformity
  7. Rising PaCO2 & decrease in pH
25
Q

Breathing - How to recognise breathing problems - What to Listen for?

A
  1. Nosiy breathing
  2. Equal breath sounds bilaterally
26
Q

Breathing - How to recognise breathing problems - What to Feel for?

A
  1. Trachea position central
  2. Equal chest expansion
  3. Surgical emphysema
  4. Percussion
27
Q

Breathing - How to treat breathing problems?

A
  1. O2
  2. Rx underlying cause - ABx for pneumonia or salbutamol nebulisers for acute asthma attacks
  3. Support breathing if inadequate - ventilate with a self-inflating bag
28
Q

How to give O2 to pt. with hypercapnic respiratory failure (COPD)?

A
  1. Give O2 via Venturi mask
  2. Sats tange 88-92%

28% Venturi mask = 4L/min
24% Venturi mask = 2L/min

29
Q

Circulation - Primary Causes of Circulation probelms:

A
  1. ACS
  2. Arrhythmias
  3. HTN
  4. Valvular disease
  5. Inherited cardiac disease
30
Q

Circulation - Secondary Causes of Circulation probelms:

A
  1. Asphyxia
  2. Hypoxaemia
  3. Hypothermia
  4. Hypovolaemia
  5. Septic shock
31
Q

Initial Rx of ACS:

A
  1. ASA 300 mg
  2. S/L GTN
  3. O2
  4. Morphine IV
  5. Anti-emetic
32
Q

Circulation - Recognising circulation problems:

A
  1. Pulse (central + peripheral) - rate, rhythm, volume, character
  2. CRT
  3. Feel peripheries - cold & clammy
  4. BP
  5. Assess organ perfusion - chest pain, mental state, urine output
  6. Assess for signs of bleeding
  7. Assess fluid losses
  8. ECG (3 lead / 12 lead)
33
Q

What does a low diastolic pressure suggest?

A
  1. Arterial vasodilation - sepsis, anaphylaxis
34
Q

What does a narrow pulse pressure suggest?

A
  1. Arterial vasoconstriction - hypovolaemia, cardiogenic shock

Normal pulse pressure = 35-45 mmHG

35
Q

Circulation - Treating circulation problems:

A
  1. IV access
  2. Consider a fluid bolus
  3. Bloods for investigation
  4. Rx underlying cause
36
Q

How to give fluid bolus?

A
  1. 14G or 16G IV cannula
  2. Bolus of 500 ml warmed crystalloid solution - Hartmann’s solution or 0.9% NaCL
  3. Over ≤ 15 min
  4. Recheck BP & PR
  5. Aim SBP ≥ 100 mmHg
  6. No change - repeat bolus

HF pt’s - give 250 ml fluid bolus

37
Q

Disability - Abnormal conscious level can be caused by:

A
  1. Profound hypoxia
  2. Hypercapnia
  3. Hypoglycaemia
  4. Postictal state following seizures
  5. Cerebral hypoperfusion due to a low blood pressure
  6. Drugs - sedatives or analgesics
38
Q

Disability - Recognising neurological problems:

A
  1. ACVPU or GCS
  2. Pupil size and reactivity to light
  3. Blood glucose
  4. Drug chart
39
Q

Disability - Treating neurological problems:

A
  1. R/V and treat ABC
  2. Correct blood glucose if level is < 4.0
  3. If the airway is not protected - place pt. in L lateral position to prevent aspiration
  4. Give antidote for any drug-induced causes of low conscioussness
40
Q

How to Rx hypoglycaemia if blood glucose ≤ 4?

A
  1. Initial dose - 50 ml of 10% glucose IVI
  2. Further doses - use 10% glucose
  3. Total dose - 250 ml 10% glucose
41
Q

Exposure - Recognising exposure problems:

A
  1. Perform a head-to-toe examination of the pt.
  2. Check both their front & back passages
  3. Remove clothing - look for bleeding, rashes, limb swelling
  4. Maintain pt’s dignity
  5. Measure pt’s temp
42
Q

Exposure - Treating exposure problems:

A
  1. Address any issues from examination
  2. Remember to maintain pt’s dignity
  3. Avoid heat loss
43
Q

A colleague calls you over to help with Sunita, a 22-year-old patient. She is feeling very short of breath and is wheezy. She has a past medical history of asthma and a recent cold. You ask your colleague to call for extra help and start an A-E assessment.

Which of the following suggests that her airway is not obstructed

She is able to speak/ She is wheezy/ She is short of breath

A
  1. She is able to speak

To be able to speak, you have to have air move across the vocal cords. Even though someone might not be able to speak in full sentences, being able to speak in a normal tone suggests that the upper airway is clear.

Wheezing arises from lower airway constriction and is heard in expiration. Partial upper airway obstruction may be associated with stridor which is an inspiratory noise.

Shortness of breath is a non-specific symptom which can occur in breathing or circulatory problems. It cannot be used alone to assess airway patency.

44
Q

You move on to assess Sunita’s breathing. She is clearly distressed and unable to talk in full sentences. Her respiratory rate is 35 breaths min-1, and she has an audible wheeze. You recognise that Sunita is having an acute asthma attack.

What do you do next?

Apply sats probe/ Administer O2/ Take full medical Hx/ Prescribe salbutamol nebuliser

A
  1. Apply sats probe
  2. Administer O2
  3. Prescribe salbutamol nebuliser

Sunita is having an acute asthma attack & treating her with O2 is important whilst further assessment& treatment is undertaken.

A sats probe gives you an important guide to the severity of her breathing difficulty.

Appropriate to arrange a prescription & give a salbutamol nebuliser.

However, as Sunita is acutely unwell, it is not appropriate to take a full Hx at this time.

45
Q

Although very short of breath, Sunita is able to answer your questions with short sentences.

What is her conscious level using the ACVPU scale?

A
  1. Alert
46
Q

You complete assessing disability and find that Sunita’s blood sugar is 6.4 mmol L-1 and her pupils are equal and reactive to light. You move on to assess exposure. There is no evidence of rashes or blood loss and her temperature is 36.8oC. A colleague has now arrived to help you. You hand over the patient using SBARD.

Which of the following make up the SBARD communication tool?

A
  1. Situation
  2. Background
  3. Assessment
  4. Recommendation
  5. Decision

S: Sunita is 22 years old and has attended the practice with shortness of breath and wheezing.
B: She is known to be asthmatic and has had a recent cold.
A: When I assessed her she had a RR of 35 min-1, was wheezy and unable to talk in full sentences. She has a tachycardia of 125 min-1. I have given her O2 and a salbutamol nebuliser.
R: I recommend we call an ambulance and send her to hospital urgently.
D: We have agreed that Sunita needs to be reviewed in hospital and I will call 999 for an ambulance.

ILS Course - A to E Training & Solutions Ltd (12 decks)

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