Читать книгу The Nursing Associate's Handbook of Clinical Skills - Группа авторов - Страница 165

Airway

Breathing

Circulation

Disability

Exposure

The ABCDE assessment is a systematic assessment of the body systems. The systematic approach ensures that all body systems are assessed in decreasing importance to the patient’s deterioration. An intervention is required for each abnormal finding before moving onto the next element.

Completing an ABCDE assessment enables the practitioner to complete a comprehensive assessment of not only the clinical observations but also the signs and symptoms which can be found using:

 Look

 Listen

 Feel

A great deal of patient information is held and should be used as a part of the patient assessment, as well as planning for escalation:

 The medical notes – Inpatients in hospitals are ‘clerked’ at their start of their admission to hospital. This is where the admitting doctors (or other admitting clinicians) write information obtained from their first assessment of the patient, such as initial presentation, investigation findings and provisional diagnoses. The clerking is particularly useful as it will list the patient’s past medical history, their medications at the time of arrival, allergies, a social history and other information which may be useful. Review the last few entries from ward rounds and other visits from other healthcare professionals – what is the patient’s current condition? What plan of treatment is currently in place for this patient?

 The observation and fluid chart – The trend of the patient’s observations is just as important as the latest single set of observations. Has the patient been declining slowly or has there been a sudden deterioration in their vital signs? Has there been any change in their urine output?