ABCDE Assessment For Every Topic Flashcards

1
Q

ABCDE Assessment Asthma.

What is the first step of an ABCDE assessment for asthma?

A
  • Assess the area for safety
  • Early call for help
  • Appropriate PPE
  • Maintain dignity
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2
Q

ABCDE Assessment of Asthma

What do you conduct the Airway assessment in asthma?

A

Look, Listen and Feel Approach.

Lookโ€”> For chest + abdominal movements, use of accessory muscles ๐Ÿ’ช . Is there a presence if blood/ vomit or foreign bodies in the mouth ๐Ÿ‘„, presence of swelling and assess the patients colour.

Listen โ€”> listen for noises when when the patient is breathing such as wheezing, snoring, crowing, an inspiratory strider ( indicates collapse in tissue above vocal cords) or an expiratory wheeze.

Feel โ€”> For airflow at the mouth and nose.

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3
Q

How do you assesses if someone had a patient airway, semi occluded airway, or fully occluded/ blocked airway.

A
  • Patent โ€”> patient has no issues communicating
  • semi- occluded โ€”> Can cough and you can hear sounds such as wheezing, gurgling, snoring ๐Ÿ’ค etc
  • Fully occluded/ Blocked โ€”> Patient appears to cough but you cannot hear any sounds.
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4
Q

ABCDE Assessment

In an Asthma attack what would you expect to observe during an airway assessment?

A
  • wheezing
  • Cyanosis of the lips
  • Respiratory distress
  • Use of accessory muscles
    Donโ€™t forget to go into detail in the exam about what causes these at a cellular level.
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5
Q

ABCDE Assessment for Asthma

How do you conduct the breathing assessment in asthma?

A

Look, Listen, Feel approach.

Look โ€”> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips ๐Ÿ‘„ and tongue ๐Ÿ‘…. Ability to hold a conversation. Position of the trachea.

Listen โ€”> Ability to cough ๐Ÿ˜ท, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.

Feel โ€”> Chest Movement

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6
Q

ABCDE Assessment of Asthma

In an asthma attack what would you expect to observe during the breathing assessment?

A
  • Respiratory distress due to acidosis
  • Cyanosis
  • Use of accessory muscles

Please explain these in detail when in the exam

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7
Q

ABCDE Assessment

How do you conduct a circulation assessment in asthma?

A

Can be done by working your way either up or down an arm

  • Assess Heart โค๏ธ rate, rhythm ๐ŸŽถ, and amplitude
  • Assess BP ( if low possible bleeding)
  • Assess colour of hands + fingers (cyanosis)
  • Assess limb ๐Ÿฆต temperature ๐Ÿค’
  • Assess capillary refill time
  • Consider urine output ( if BP is low urine out put will be low)
  • nausea or vomiting ๐Ÿคฎ ? ( low BP can cause vomiting ๐Ÿคฎ and nausea)
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8
Q

ABCDE Assessment of asthma

In an asthma attack what would you expect to observe during a circulation assessment?

A
  • Expect them to be cardiovascular ๐Ÿซ€ unstable due to a lack of O2
  • I would expect them to have a low BP due to the lack of O2 effecting the function of the heart
  • Due to the low BP I would expect them to have a low urine output
  • cyanosis of the extremities such as the fingers or toes.
  • if the patient is frightened I would expose the them to have a fast heart rate due to the adrenaline
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9
Q

ABCDE Assessment of Asthma

How do you conduct a disability assessment in asthma?

A
Assess using ACVPU 
A= Alert ๐Ÿšจ 
C= newly Confused ๐Ÿคทโ€โ™€๏ธ 
V= responds to Vocal Stimuli 
P = responds to painful ๐Ÿ˜ฃ stimuli 
U = Unressponsive 

An assessment of blood ๐Ÿฉธ glucose levels will be done also

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10
Q

ABCDE Assessment of Asthma

In an asthma attack what would expect to observe during a disability assessment?

A
  • impaired level of consciousness due to a lack of O2 to the brain
  • Really high blood ๐Ÿฉธ glucose levels โ€”> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood ๐Ÿฉธglucose to rise
  • Really low blood ๐Ÿฉธ glucose levels โ€”> when you run out of Glycogen (the glucose store) blood ๐Ÿฉธ sugar levels will fall rapidly.
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11
Q

ABCDE Assessment of asthma

How do you conduct an exposure assessment in asthma?

A
  • Full exposure is required.
  • Respect โœŠ of patients dignity
  • Minimise heat loss
  • Assess for rashes, fractures, bleeding ๐Ÿฉธ, swelling
  • Assess for allergic reaction
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12
Q

ABCDE Assessment of Asthma

In an asthma attack what would you expect to observe in an exposure assessment?

A
  • You would observe cyanosis.

- Potential allergic reaction.

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13
Q

ABCDE Assessment for Pneumonia

What is the first step of an ABCDE assessment for Pneumonia.

A
  • Assess the area for safety
  • Early call for help
  • Appropriate PPE
  • Maintain dignity
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14
Q

ABCDE Assessment for Pneumonia

How do you conduct the Airway assessment for Pneumonia

A

Look, Listen, and Feel approach..

Look โ€”> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood ๐Ÿฉธ, vomit ๐Ÿคฎ or other foreign bodies in the mouth. Assess presence of swelling and colour.

Listen โ€”> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.

Feelโ€”> For airflow at the mouth ๐Ÿ‘„ or nose ๐Ÿ‘ƒ

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15
Q

ABCDE Assessment for Pneumonia

What would you expect to observe conducting an airway assessment on someone with pneumonia?

A
  • Cyanosis - Lack of oxygen reaching the cardiovascular ๐Ÿซ€ system. Due the alveoli being blocked with fluid.
  • Green sputum. Caused by iron released from white blood cells with a free radical of O2 that has caused the cell to rupture.
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16
Q

ABCDE Assessment For Pneumonia

How do you conduct a breathing assessment for pneumonia?

A

Look, Listen, Feel approach.

Look โ€”> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips ๐Ÿ‘„ and tongue ๐Ÿ‘…. Ability to hold a conversation. Position of the trachea.

Listen โ€”> Ability to cough ๐Ÿ˜ท, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.

Feel โ€”> Chest Movement

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17
Q

ABCDE Assessment for Pneumonia.

What would you expect to observe conducting a breathing assessment on someone with pneumonia

A
  • Respiratory distress due to acidosis
  • Fast resp rate to try and reduce the lactate levels and raise the Ph
  • Use of accessory muscles
  • Breathlessness
  • Rhales

Please explain these in more detail in the exam

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18
Q

ABCDE Assessment for Pneumonia

How do you conduct a circulation assessment for Pneumonia?

A

Can be done by working your way either up or down an arm

  • Assess Heart โค๏ธ rate, rhythm ๐ŸŽถ, and amplitude
  • Assess BP ( if low possible bleeding)
  • Assess colour of hands + fingers (cyanosis)
  • Assess limb ๐Ÿฆต temperature ๐Ÿค’
  • Assess capillary refill time
  • Consider urine output ( if BP is low urine out put will be low)
  • nausea or vomiting ๐Ÿคฎ ? ( low BP can cause vomiting ๐Ÿคฎ and nausea)
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19
Q

ABCDE Assessment for Pneumonia.

What would you expose to observe when conducting a circulation assessment on someone with pneumonia?

A
  • Expect them to be cardiovascular ๐Ÿซ€ unstable due to a lack of O2
  • I would expect them to have a low BP due to the lack of O2 effecting the function of the heart
  • Due to the low BP I would expect them to have a low urine output
  • cyanosis of the extremities such as the fingers or toes.
  • if the patient is frightened I would expose the them to have a fast heart rate due to the adrenaline
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20
Q

ABCDE Assessment for Pneumonia

How do you conduct a disability assessment for pneumonia

A
Assess using ACVPU 
A= Alert ๐Ÿšจ 
C= newly Confused ๐Ÿคทโ€โ™€๏ธ 
V= responds to Vocal Stimuli 
P = responds to painful ๐Ÿ˜ฃ stimuli 
U = Unressponsive 

An assessment of blood ๐Ÿฉธ glucose levels will be done also

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21
Q

ABCDE Assessment pneumonia.

What would you expect to observe in a disability assessment on someone with pneumonia?

A
  • Hypoxic confusion
  • Impaired level of consciousness due to a lack of O2 to the brain due to the alveoli sacs being filled with fluid.
  • Really high blood ๐Ÿฉธ glucose levels โ€”> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood ๐Ÿฉธglucose to rise
  • Really low blood ๐Ÿฉธ glucose levels โ€”> when you run out of Glycogen (the glucose store) blood ๐Ÿฉธ sugar levels will fall rapidly.
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22
Q

ABCDE Assessment for Pneumonia

How do you conduct an exposure assessment for Pneumonia?

A
  • Full exposure is required.
  • Respect โœŠ of patients dignity
  • Minimise heat loss
  • Assess for rashes, fractures, bleeding ๐Ÿฉธ, swelling
  • Assess for allergic reaction
23
Q

ABCDE Assessment for Pneumonia

What would you expect to observe when conducting an exposure assessment on someone with pneumonia?

A
  • Hot to touch. Due to them having a temperature

Explain in more detail for the exam

24
Q

ABCDE Assessment for anaphylaxis

How do you conduct an airway assessment for Anaphylaxis

A

Look, Listen, and Feel approach..

Look โ€”> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood ๐Ÿฉธ, vomit ๐Ÿคฎ or other foreign bodies in the mouth. Assess presence of swelling and colour.

Listen โ€”> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.

Feelโ€”> For airflow at the mouth ๐Ÿ‘„ or nose ๐Ÿ‘ƒ

25
Q

ABCDE Assessment for Anaphylaxis

What would you expect to observe when conducting an airway assessment on someone experiencing anaphylaxis

A
  • Orbital swelling ( swelling around the ๐Ÿ‘€)
  • Upper air way obstruction from angioedema of the tongue ๐Ÿ‘…, pharynx, larynx, Bronchospasm.
  • Chest tightness
  • Cough/ wheezing
  • Rhinitis
  • sneezing ๐Ÿคง/ congestion
  • Patient has difficulty breathing and swallowing. Throat feeling like it is closing up.
  • Hoarse voice
  • Stridor ( that is high pitched)caused by upper airway obstruction
26
Q

ABCDE Assessment for Anaphylaxis

How do you conduct a breathing assessment for anaphylaxis

A

Look, Listen, Feel approach.

Look โ€”> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips ๐Ÿ‘„ and tongue ๐Ÿ‘…. Ability to hold a conversation. Position of the trachea.

Listen โ€”> Ability to cough ๐Ÿ˜ท, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.

Feel โ€”> Chest Movement

27
Q

ABCDE Assessment for Anaphylaxis

What would you expect to observe when conducting a breathing assessment on someone experiencing anaphylaxis?

A
  • Shortness of breath/ increased resp rate
  • Wheeze
  • Patient becoming tired๐Ÿ˜ด
  • Confusion caused by hypoxia
  • Cyanosis (usually a late sign)
  • Respiratory arrest
28
Q

ABCDE Assessment for Anaphylaxis

How do you conduct a circulation assessment for anaphylaxis?

A

Can be done by working your way either up or down an arm

  • Assess Heart โค๏ธ rate, rhythm ๐ŸŽถ, and amplitude
  • Assess BP ( if low possible bleeding)
  • Assess colour of hands + fingers (cyanosis)
  • Assess limb ๐Ÿฆต temperature ๐Ÿค’
  • Assess capillary refill time
  • Consider urine output ( if BP is low urine out put will be low)
  • nausea or vomiting ๐Ÿคฎ ? ( low BP can cause vomiting ๐Ÿคฎ and nausea)
29
Q

ABCDE Assessment for Anaphylaxis

What would you expect to observe in a circulation assessment on someone experiencing anaphylaxis?

A
  • Faintness, Hypotension, arrhythmia, hypvolemic shock.
  • Chest pain.
  • Signs of shock ( pale/ clammy)
  • Increased heart rate
  • Low BP causing the Faint/ dizzy feeling
  • Decreased consciousness or loss of consciousness
  • Cardiac arrest.
30
Q

ABCDE Assessment for Anaphylaxis

How do you conduct a disability assessment for anaphylaxis?

A
Assess using ACVPU 
A= Alert ๐Ÿšจ 
C= newly Confused ๐Ÿคทโ€โ™€๏ธ 
V= responds to Vocal Stimuli 
P = responds to painful ๐Ÿ˜ฃ stimuli 
U = Unressponsive 

An assessment of blood ๐Ÿฉธ glucose levels will be done also

31
Q

ABCDE Assessment for Anaphylaxis

What would you expect to see when you conduct a disability assessment on someone experiencing anaphylaxis?

A
  • Initial reaction may be loss of consciousness
  • Patient may describe โ€˜a sense of doomโ€™
  • Patient may become confused or agitated
  • Can experience gastrointestinal symptoms
  • Lack of perfusion to the CNS and the GI tract manifests as confusion, nausea.
32
Q

ABCDE Assessment for Anaphylaxis

How do you conduct an exposure assessment for anaphylaxis?

A
  • Full exposure is required.
  • Respect โœŠ of patients dignity
  • Minimise heat loss
  • Assess for rashes, fractures, bleeding ๐Ÿฉธ, swelling
  • Assess for allergic reaction
33
Q

ABCDE Assessment for Anaphylaxis

What would you expect to observe when conducting an exposure assessment on someone experiencing anaphylaxis?

A
  • Skin / mucosal changes ( this is the first feature and present in over 80% of anaphylactic reactions)
  • May be erythema ( a patchy or generalised red rash)
  • Cirticaria ( hives)
  • Angioedema - swelling of the deeper tissues, most common in the eyelids, lips and sometimes in the mouth and throat.
34
Q

ABCDE Assessment for Renal dysfunction

How do you conduct and airway assessment for Renal Dysfunction?

A

Look, Listen, and Feel approach..

Look โ€”> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood ๐Ÿฉธ, vomit ๐Ÿคฎ or other foreign bodies in the mouth. Assess presence of swelling and colour.

Listen โ€”> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.

35
Q

ABCDE Assessment for Renal dysfunction

What would you expect to observe when conducting an airway assessment for renal dysfunction?

A
  • Increased resp rate - due to phrenic nerve stimulation and acidosis
  • Nausea/ vomit - blood redirected to major organs reducing Gi tract activity
36
Q

ABCDE Assessment for Renal dysfunction

How do you conduct a breathing assessment for Renal Dysfunction?

A

-Look, Listen, Feel approach.

Look โ€”> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips ๐Ÿ‘„ and tongue ๐Ÿ‘…. Ability to hold a conversation. Position of the trachea.

Listen โ€”> Ability to cough ๐Ÿ˜ท, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.

Feel โ€”> Chest Movement

37
Q

ABCDE Assessment for Renal dysfunction

What would you expect to observe when conducting a breathing assessment for renal dysfunction?

A
  • Increased resp rate due to acidosis

- Nausea, Vomit may be present

38
Q

ABCDE Assessment for Renal dysfunction

How do you conduct a circulation assessment for renal dysfunction?

A
  • Can be done by working your way either up or down an arm
  • Assess Heart โค๏ธ rate, rhythm ๐ŸŽถ, and amplitude
  • Assess BP ( if low possible bleeding)
  • Assess colour of hands + fingers (cyanosis)
  • Assess limb ๐Ÿฆต temperature ๐Ÿค’
  • Assess capillary refill time
  • Consider urine output ( if BP is low urine out put will be low)
  • nausea or vomiting ๐Ÿคฎ ? ( low BP can cause vomiting ๐Ÿคฎ and nausea)
39
Q

ABCDE Assessment for Renal dysfunction

what would you expect to observe when conducting a circulation assessment for Renal dysfunction

A
  • Limbs will be cold due to poor perfusion
  • Low or decreased BP due to cardiovascular collapse
  • Vomit this can be caused by Low BP
  • Decreased urine output caused by poor perfusion.
40
Q

ABCDE Assessment for Renal dysfunction

How do you conduct a disability assessment for renal dysfunction?

A
Assess using ACVPU 
A= Alert ๐Ÿšจ 
C= newly Confused ๐Ÿคทโ€โ™€๏ธ 
V= responds to Vocal Stimuli 
P = responds to painful ๐Ÿ˜ฃ stimuli 
U = Unressponsive 

An assessment of blood ๐Ÿฉธ

41
Q

ABCDE Assessment for Renal dysfunction

What would you expect to observe during a disability assessment?

A
  • Altered level of consciousness - Hypoxia
  • Increased heart rate - due to the release of adrenaline
  • Really high blood ๐Ÿฉธ glucose levels โ€”> Adrenaline can cause the liver to turn glycogen ( glucose stores) into glucose causing blood ๐Ÿฉธglucose to rise
  • Really low blood ๐Ÿฉธ glucose levels โ€”> when you run out of Glycogen (the glucose store) blood ๐Ÿฉธ sugar levels will fall rapidly.
42
Q

ABCDE Assessment for Renal dysfunction

How do you conduct an exposure assessment for renal dysfunction?

A
  • Full exposure is required.
  • Respect โœŠ of patients dignity
  • Minimise heat loss
  • Assess for rashes, fractures, bleeding ๐Ÿฉธ, swelling
  • Assess for allergic reaction
43
Q

ABCDE Assessment for Renal dysfunction

What would you expect to observe when conducting an exposure assessment for Renal dysfunction?

A
  • Vomit
  • poor urine output
  • cyanosis
44
Q

ABCDE Assessment Seizure and epilepsy

How do you conduct an airway assessment for seizure and epilepsy?

A

Look, Listen, and Feel approach..

Look โ€”> For chest and abdominal movements + abnormal movements, accessory muscle use, presence of blood ๐Ÿฉธ, vomit ๐Ÿคฎ or other foreign bodies in the mouth. Assess presence of swelling and colour.

Listen โ€”> For noises when breathing (gurgling, snoring, crowing inspiratory strider expiratory wheeze.

45
Q

ABCDE Assessment Seizure and epilepsy

What would you expect to observe during an airway assessment in seizure and epilepsy?

A
  • Airway occlusion, tongue thrusting/ biting excessive salivar
  • During convulsions we try to ensure the patient is not at risk from Iโ€™m just but make no attempt to put anything in their mouth or between teeth
  • Attempting to insert and oropharyngeal airway or other airway while the patient is actively fitting is to be avoided
46
Q

ABCDE Assessment Seizure and epilepsy

How to conduct a breathing assessment for seizure and epilepsy?

A
  • Look, Listen, Feel approach.

Look โ€”> Assess the resp rate, depth and pattern of breathing. Use of accessory muscles? Colour cyanosis of the lips ๐Ÿ‘„ and tongue ๐Ÿ‘…. Ability to hold a conversation. Position of the trachea.

Listen โ€”> Ability to cough ๐Ÿ˜ท, amount of sputum, odour, consistency of sputum.
Evidence of gurgling, snoring, crowing, inspiratory strider expiratory wheeze.

Feel โ€”> Chest Movement

47
Q

ABCDE Assessment Seizure and epilepsy

what would you expect to observe when conducting a breathing assessment in seizure and epilepsy?

A
  • Respiratory distress
  • Shortness of breath/ increased resp rate or apnoea
  • Confusion/ cyanosis

Give high flow O2

48
Q

ABCDE Assessment Seizure and epilepsy

How do you conduct a circulation assessment for seizure and epilepsy?

A
  • Can be done by working your way either up or down an arm
  • Assess Heart โค๏ธ rate, rhythm ๐ŸŽถ, and amplitude
  • Assess BP ( if low possible bleeding)
  • Assess colour of hands + fingers (cyanosis)
  • Assess limb ๐Ÿฆต temperature ๐Ÿค’
  • Assess capillary refill time
  • Consider urine output ( if BP is low urine out put will be low)
  • nausea or vomiting ๐Ÿคฎ ? ( low BP can cause vomiting ๐Ÿคฎ and nausea)
49
Q

ABCDE Assessment Seizure and epilepsy

What would you expect to observe when conducting a circulation assessment in seizure and epilepsy?

A
  • Cardiovascular instability due to hypoxia
  • Decreased consciousness
  • Bladder/ Bowel incontinence
50
Q

ABCDE Assessment Seizure and epilepsy

How do you conduct a disability assessment in seizure and epilepsy?

A
-Assess using ACVPU 
A= Alert ๐Ÿšจ 
C= newly Confused ๐Ÿคทโ€โ™€๏ธ 
V= responds to Vocal Stimuli 
P = responds to painful ๐Ÿ˜ฃ stimuli 
U = Unressponsive 

An assessment of blood ๐Ÿฉธglucose

51
Q

ABCDE Assessment Seizure and epilepsy

What would you expect to observe when conducting a disability assessment in seizure and epilepsy?

A
  • Altered level of consciousness
  • Abnormal limb movements and eye movements
  • Gastrointestinal symptoms
    Check blood glucose
  • HYPOGLYCAEMIA
52
Q

ABCDE Assessment Seizure and epilepsy

How do you conduct an exposure assessment in seizure and epilepsy?

A
  • Full exposure is required.
  • Respect โœŠ of patients dignity
  • Minimise heat loss
  • Assess for rashes, fractures, bleeding ๐Ÿฉธ, swelling
  • Assess for allergic reaction
53
Q

ABCDE Assessment Seizure and epilepsy

What would you expect to observe during an exposure assessment in seizure and epilepsy?

A

Reasses for fractures, bleeding and rashes that may have been obtained during the seaizure