ASSESSMENT – PRIMARY
Patient condition often dictates what area is covered first in our assessment; however we should still observe some type of systematic progression to avoid overlooking important assessment areas. All assessments whether it be rapid emergency exclusion techniques or a head to toe assessment all start with meeting the patient
So what do you see? Are they drowsy, slumped over or lying too flat, breathless, gurgling, pale, and sweaty or are they safe, awake and looking back at you wondering what you are staring at? “I was just seeing how you looked today” is your answer and that in itself has opened communication and initiated a partnership between you and your patient
Primary assessment or initial health impression
Look hard and closely to perform a 12 second “good to go” assessment – as you can make an immediate safety assessment of any patient in the first 12 seconds. This is your initial impression which allows you to determine if any immediate intervention is required. This is the trigger for alarm every nurse needs and develops with time and practice
To this ABC add;
D for Disability / Diabetes – neurologically intact? What is the patient’s normal (if they have fallen is there an obvious fracture or have they lost feeling in their legs?) low glucose can be insidious and show as decreased conscious state, confusion, sweatiness and clammy skin, if concerned add it to your rapid assessment process
E for Environment / Exposure, can they safely stay where they are, are they wet or hot / cold or inappropriately dressed? Pull back the sheets and look and feel the extremities, are they cold or swollen or did the sheets hide a clue like blood to the current situation
This is a modified ABCDE Algorithm (based on the Australian Resuscitation Council ALS2 course (2011)
If there are any concerns regarding absence of “Signs of Life” – not breathing normally, unresponsive and not moving – commence CPR and ring 3 bells / Call for help / RRS / MET. Even if they are gasping an assumption of cardiac arrest should be made and CPR commenced
What targeted questions should we ask ourselves to identify issues or decrease concerns? Let’s stop look, listen and feel – perform our rapid PRIMARY SURVEY: Are they alive, safe and are they going to stay safe?
A: Approach and Assess Appearance – Are they conscious and can they speak?
- Look – Are they awake; are their eyes open; what position are they lying in?
- Listen – Speak to them. Do they speak back?
- Feel – What is your general impression of the situation?
B: Breathing – Are they breathing and do they have an open airway?
B: Breathing – How well are they breathing, are they conscious?
- Look – Is their chest wall moving as they breathe, do they need to sit up?
- Listen – Can you hear any adventitious breath sounds indicating a partially occluded airway, such as wheezing, gurgling, or snoring?
- Feel – Is the chest wall moving appropriately with respirations?
C: Circulation – Do they have a pulse or normal colour, are they conscious?
C: Circulation – Are they bleeding or have chest pain?
- Look – Is there any bleeding?
- Listen – Can you hear a heartbeat?
- Feel – Time the capilliary refill / can you feel a carotid, radial, femoral pulse?
D: Diabetes – Are they a known diabetic?
D: Disability – Is their neck or back at risk of injury?
- Look – Do you see any obvious injuries or deformities?
- Listen – Where are they complaining of pain?
- Feel – Where does it hurt? As you touch them, where can you cause pain?
E: Environment – Can they stay where they are?
E: Exposure – Are they protected for the environment?
- Look – Where are they currently, are they safe or need closer observation?
- Listen – Are they complaining about being hot, cold, or wet?
- Feel – Is their skin warm, dry, cold, or wet?
You can now, based on you collected observations, decide if the patient is safe, in any immediate health or environmental danger and able to maintain a therapeutic partnership with you. If not use your acquired knowledge an implement a plan, seek senior nursing, medical or RRS/MET assistance but do something
If all is well you may continue to triage the rest of the patients in your care, by performing this very quick, very immediate assessment on all of them and by comparing your primary assessment summary, decide who needs immediate help (if any) and where your time is required first, second and so on. Should it be indicated move on to performing a secondary and even tertiary assessment on your patients, both you and they will be safer for it
Remember at all times that should you find something in your assessment that concerns you or causes you to escalate the care plan for your patient you MUST do the following 2 things;
- Document – in the medical record, on the observation chart and on your handover for the next shift – what you found, what you did, who helped and what was the outcome
- Increase your observations – adjust your period between observations appropriately to the circumstance. If you called the RRS/MET team, now they have left do you believe 4 hourly vital signs are still going to give you the information you require to maintain this patient’s safety?
PLEASE NEVER LEAVE A DETERIORATING PATIENT WITHOUT AN AGREED PRIORITY MANAGEMENT AND REVIEW PLAN
Our assessment skills have given us clues as to what if anything is wrong, acute or chronic. Clever stuff, keep up the great work!
Clinical Examination : a systematic guide to physical diagnosis 6th Edition 2010 by Nicholas J. Talley, Simon O’Connor.