Skill List > ABCDE Assessment
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Duncan Smith MSc MScN DTN PGCert (Ed) FHEA RN
Reviewed: June 2020
Learning Objective
The purpose of this learning material is to provide you with a resource to: Facilitate the development of new knowledge • Build on existing knowledge • Test knowledge • Assess the skill in practice.

INTRODUCTION

ABCDE is a framework to facilitate organised and systematic patient assessment (Resuscitation Council 2015). Whilst a number of different approaches to patient assessment exist, ABCDE is considered to be particularly effective in an acute or deteriorating patient context. ABCDE assessment permits the identification of patient problems by order of severity enabling suitable interventions to be delivered according to clinical priority and patient need (Smith & Bowden 2017). The measurement of vital signs and the calculation of a National Early Warning Score 2 (Royal College of Physicians 2017) forms an integral part of ABCDE assessment. However, performing an ABCDE assessment involves a more in-depth assessment than the measurement of vital signs alone. Further clinical information is collected around the vital signs, to develop a more comprehensive picture of the patient’s status, to facilitate effective clinical decision-making, and to ensure that patient receives safe and effective care (Levett-Jones et al. 2010).

The overarching principles of ABCDE assessment are:

  • Use the ABCDE approach to both assess a patient and to deliver interventions within your role as a student nurse/registered nurse.
  • Assess systematically and re-assess using the same structure (to identify the response to, or effect of, any delivered interventions).
  • Measure and record vital signs/NEWS2 as part of the wider assessment.
  • Document findings accurately and comprehensively according to local policy.
  • Recognise when the patient requires input from other members of the healthcare team and escalate using a structured communication tool.
(Smith & Bowden 2017)

PROCEDURE

Assessment and safety


Although ABCDE is typically performed in an acute care setting, it is sufficiently versatile to be used in any clinical environment. ABCDE is an assessment framework that incorporates a range of different discrete clinical skills (outlined and rationalised below). Whilst any practitioner can use the ABCDE approach to assess a patient, the person undertaking the assessment should only enact the specific skills appropriate to their role e.g., a 1st year student nurse may not yet be proficient in chest auscultation but could still broadly apply the ABCDE approach. Given the proximity to the patient, donning a disposable apron would be appropriate. The need for further personal protective equipment should be judged on an individual basis. 

  1. Perform hand hygiene before patient contact. Put on additional PPE as required by the patient’s condition.
  2. Check the patient’s identity – using the patient’s name-band and/or verbally, according to local policy.
  3. Introduce yourself and provide a brief explanation of the purpose of the ABCDE assessment, to obtain the patient’s consent and cooperation. Ensure that the patient and family understand ABCDE assessment. Answer questions as they arise and reinforce information as needed. If the patient is unresponsive follow basic life support protocol.
  4. Note the general condition of the patient (including the patient’s position and posture, colour and demeanour).
    Rationale  This ‘end of the bed’ assessment, provides an opportunity to rapidly identify the patient’s level of comfort or distress, and also may inform decisions regarding the personal protective equipment required to complete the assessment safely (Rawles et al 2015).
  5. Assess for patency of the airway:
    1. Ask an open question (e.g., ‘how are you?’) and take note of the patient’s ability to complete full sentences.
    2. Listen for any abnormal upper airway sounds (e.g., stridor, gurgling).
    3. If suspicious of a severe allergic reaction, inspect the lips and tongue for swelling.
      Rationale – Asking an open question early in your assessment helps to develop rapport with the patient, and also provides rapid and valuable clinical information. A responsive patient with a patent airway should answer in full sentences with normal pitch and tone to the voice, and no added sounds suggestive of partial upper airway obstruction (e.g., snoring or stridor). Any evidence of airway compromise should be considered a medical emergency and escalated immediately (Resuscitation Council 2015).
  6. Assess the rate, effort and efficacy of breathing:
    1. Measure and record the patient’s peripheral oxygen saturations (SpO2).
    2. Check that any supplementary oxygen therapy is being delivered correctly and in accordance with the prescription.
      Rationale – Peripheral oxygen saturations (SpO2) are measured as part of the standard set of vital signs for NEWS2 (RCP 2017). An accurate SpO2 measurement enables the identification of hypoxaemia (low blood oxygen concentration) and permits the titration of supplementary oxygen therapy to specified targets. The British Thoracic Society provides target ranges for patients with (88–92%) and without (94–98%) chronic obstructive pulmonary disease (O’Driscoll et al. 2008).      Be aware that accurate SpO2 measurement is contingent on an adequate peripheral circulation. As such, a critically unwell patient may not have measurable SpO2. In these situations, it may be appropriate to deliver high-flow oxygen (i.e., 15 L/min-1) via a face mask with a reservoir (a non-re-breathing mask).
    3. Measure and record the patient’s respiratory rate over a full minute.
       Rationale – Respiratory rate is recognised to be an early independent predictor of patient deterioration (Escobar et al. 2012). Despite this, there is evidence that respiratory rate is frequently inaccurately recorded (Badawy et al. 2017). As such, it is important that the respiratory rate is counted for a full minute.
    4. Observe for the use of accessory muscles of breathing and for full, equal and symmetrical expansion of the chest wall.
      Rationale – In health, normal breathing is relaxed, quiet and effortless involving the diaphragm and, to a lesser extent, the intercostal muscles (Herring et al. 2018). Various disease processes can increase the load placed on the respiratory system, resulting in visible changes to the mechanics of breathing and the use of accessory muscles to aid ventilation (Steen 2010). If the patient is using muscles of the neck, shoulders and abdomen during ventilation, this is ominous and suggests that work of breathing is increased (Smith & Bowden 2017). Likewise, patients with diseases of the lung, may develop asymmetry of the chest (i.e., one side of the chest moves more than the other) or reduced chest wall expansion, where breathing is noticeably shallow. 
    5. Feel the chest wall for any abnormalities (e.g., pain, deformity, surgical emphysema).
      Rationale – If a patient complains of chest pain, palpation (feeling) of the chest wall can be helpful to identify if the pain is provoked by touch and/or if the pain is localised to a specific region of the chest. Chest pain that occurs or worsens on palpation may be associated with inflammation or injury to the chest wall (Japp & Robertson 2018). Systematic palpation of the chest wall can also help to confirm symmetry of expansion, and other abnormalities e.g., deformities or surgical emphysema, where the lung is injured and air leaks into the subcutaneous tissues (Adam et al. 2017). 
    6. Listen for audible added sounds of breathing (e.g., wheezing). 
      Rationale – Uninterrupted airflow through the respiratory tract is typically silent resulting in normal, quiet breathing. Disrupted or turbulent airflow from disease-related changes to the airways and/or lung tissue can result in adventitious (abnormal) sounds (Innes et al. 2018). Some of these sounds – particularly wheeze – can be heard with the naked ear.
    7. If the patient is coughing, assess the adequacy and character of the cough and, if the cough is productive, the sputum. Rationale – In health, the cough should be adequate to mobilise secretions into the pharynx (throat) so that they can be expectorated. Some diseases cause dysfunction of the mucociliary elevator, increasing the likely of sputum being retained causing occlusion or ‘plugging off’ of the airways and/or infection (Smith & Bowden 2017). Similarly, patients with neuromuscular disorders or general deconditioning (e.g., from a prolonged period of critical illness) can have a weak or impaired cough (Adam et al 2017). Such patients may require support with suctioning of the airways, and benefit from physiotherapy to mobilise secretions and to optimise positioning for sputum clearance (Smith & Bowden 2017). If the patient has a productive cough, the sputum should be examined for colour, consistency, quantity and odour (Innes et al. 2018). The presence of blood in the sputum (haemoptysis) can signal serious underlying disease and should always be reported (Japp & Robertson 2018). 
    8. If proficient, auscultate the chest (anteriorly and posteriorly) using the diaphragm of the stethoscope.
      Rationale – Some adventitious (added) breath sounds, including crackles, are typically only heard with the aid of the stethoscope (Smith & Bowden 2017). If proficient, auscultate the anterior chest wall from the lung apices, through the mid-zones, to the lower zone (Innes et al. 2018). Ideally, ‘a stepladder approach’ should be used to facilitate constant comparison between the left and right lungs (Proctor & Rickards 2020). Listen to a full breath cycle (e.g., full inspiration followed by full expiration) at each point (Innes et al. 2018). A minimum of 5 points should be auscultated bilaterally – on the anterior and posterior chest – ending at the level of the seventh intercostal space (Proctor & Rickards 2020). Note the location and character of any adventitious (added) breath sounds. Be mindful that in some disease processes normal gas-filled lung may be substituted by a tissue that does not aerate or aerate as well (e.g., fluid) leading to quiet or totally absent breath sounds (Japp & Robertson 2018). Significantly reduced or absent breath sounds over lung tissue is an abnormal finding and should be recorded and escalated. 
    9. Consider the need to measure peak expiratory flow rate (PEFR).
      Rationale – For patients with specific respiratory conditions, particularly asthma, measurement of peak expiratory flow rate may be required to quantify the severity of an acute episode or to assess the efficacy of treatment (e.g., to bronchodilator therapy) (Resuscitation Council 2015; Smith & Bowden 2017).
  7. Assess the circulation:
    1. Measure and record the patient’s blood pressure.
    2. Measure and record the patient’s pulse rate.
      Rationale – In clinical practice, heart rate and blood pressure are frequently measured using electronic devices. If there is any doubt about the accuracy of the measurements obtained from this equipment, then measurements should be taken using manual methods (e.g., use a sphygmomanometer to measure a BP). Palpation of a radial pulse should be undertaken even if the rate has been recorded from an electronic device (usually from the pulse oximetry probe). Feeling the pulse manually, will confirm the rate as well as enabling assessment of rhythm and character, which cannot be obtained from an electronic device (Smith & Bowden 2017).
    3. Feel the temperature of the skin at the patient’s extremities.
    4. Measure and record a peripheral capillary refill time (CRT).
      Rationale – Feeling the temperature of the patient’s extremities, and blanching the nail bed for 5 seconds to measure a peripheral capillary refill time (CRT) (normal refill after blanching is <2 seconds), will help determine if the patient has adequate peripheral perfusion or if it is reduced. Reduced peripheral perfusion is seen in patients with various types and stages of shock (Smith & Bowden 2017).
    5. Observe any peripheral vascular access devices – check that they are appropriately dated and inspect for evidence of infusion phlebitis.
       Rationale – Patency of these devices is important as they may be required subsequently for the delivery of treatment to restore circulation e.g., intravenous fluid therapy.
    6. Feel the skin temperature at the patient’s torso and measure a central CRT (e.g., blanching the skin over the patient’s sternum).
      Rationale – Patients with fever in the context of sepsis may be centrally hot to the touch but cool at the extremities. Measuring the CRT centrally (by blanching the skin over the sternum) enables comparison to the peripheral measurement already obtained.
    7. Assess the patient’s fluid status comprehensively. 
      Rationale – Inspect the skin, tongue and mucous membranes for evidence of tissue dehydration. Conversely, inspect and palpate the lower extremities and,  if appropriate, the sacral area for oedema suggestive of heart failure, fluid overload, fluid redistribution and/or impaired venous return (Smith & Bowden 2017). 
    8. Review fluid balance documentation and note the patient’s urine output if recorded. A fall in urine output (less than 0.5 mL/kg/h) may be an early indicator of an impaired circulation (Resuscitation Council 2015).
  8. Assess the disability (considering ‘disordered consciousness’):
    1. Measure and record the patient’s level of consciousness as either Alert, has evidence of new Confusion, responsive to Voice, responsive to Pain, Unresponsive.
      Rationale – Using a stepwise approach, apply different stimuli in sequence to assess the patient’s level of consciousness. If the patient is making immediate eye contact, engaging with you and their surroundings, and/or conversing appropriately, then they are considered alert on first assessment. If the patient requires a verbal stimulus to open their eyes and engage, then they are considered responsive to voice. Only if the patient does not respond to voice should an appropriate painful stimulus (e.g., a trapezius squeeze) be applied (Adam et al. 2017). If the patient does not respond to pain, then they are considered unresponsive and this should signal an immediate reassessment of their airway and rapid escalation (Resuscitation Council, 2015). A number of illness states can result in acute confusion or delirium. If a patient who was previously lucid, appears to be confused, this is a noteworthy finding and should be escalated.
    2. Consider the need for a more comprehensive assessment of the patient’s neurological status including Glasgow Coma Scale and/or examination of the pupillary light reflex.
    3. Ask if the patient is in pain and – if pain is reported – assess further using a systematic approach.
      Rationale – If the patient complains of pain, consider using a mnemonic to formulate questions to explore the pain more comprehensively. An example mnemonic would be the PQRST: Provoking/Palliating factors (What brought on the pain? What were you doing when the pain started? What measures have helped relieve the pain?); Quality (Can you describe your pain in your own words? What does it feel like?); Radiation (Can you show me where the pain is? Do you have pain anywhere else?); Severity (On a scale of 0 (no pain) to 10 (worst pain ever experienced), how would you rate your pain?); Timing (How long did it last?) (Olson & Bowden 2014). 
    4. Consider the need to perform point of care blood glucose monitoring.
      Rationale – Significant blood glucose abnormalities can reduce level of consciousness (Jevon 2010).
    5. Review the patient’s prescription documentation.
      Rationale – In a patient with a reduced conscious level, it may be appropriate to review the prescription record to exclude unintentional over-sedation from prescribed medications (e.g., opioids or benzodiazepines).
  9. Expose and examine further:
    1. Ensure that the patient’s privacy, dignity and temperature are maintained at all times.
    2. Measure and record the patient’s body temperature.
      Rationale – In the context of sepsis, patients may have deranged vital signs including either pyrexia (i.e., temperature ≥38ºC) or hypothermia (i.e., temperature ≤ 36ºC) (Dellinger et al. 2013). 
    3. Inspect the skin for surgical wounds, pressure ulcers or rashes.
      Rationale – Rashes or skin changes could indicate hypersensitivity reactions e.g., anaphylaxis (Resuscitation Council, 2015; Smith & Bowden 2017).
    4. Inspect for medical devices e.g., surgical drains, a urethral catheter.
    5. Observe for signs of blood or fluid losses and Inspect the abdominal area for bruising, distension or pulsation.
      Rationale – Look for evidence of blood loss (including bleeding per rectum or per vagina), and consider the risk of internal bleeding particularly in the trauma setting, in postoperative surgical patients, or in patients with severe pancreatitis (Japp & Robertson 2018). Patients with intra-abdominal bleeding may have abdominal pain, distension of the abdomen and/or bruising around the umbilicus or the flanks (Innes et al. 2018).
    6. Inspect and feel the calves for erythema, swelling, tenderness.
      Rationale – These findings could indicate deep vein thrombosis (Bickley 2017).
    7. Consider the need for more extensive neurovascular assessment of the lower limbs.
      Rationale – This is typically performed in patients who have undergone surgery or percutaneous procedures that accompany a risk of disruption to blood vessels and peripheral nerves (e.g., vascular or orthopaedic surgery) (Johnston‐Walker & Hardcastle 2011). The neurovascular assessment, which is typically performed distally (i.e., downstream) from the site of injury or surgery, may include assessment of CRT, peripheral pulses, colour, skin temperature, sensation and movement (Johnston‐Walker & Hardcastle 2011, Schreiber 2016). 
    8. Note the presence of anti-embolic hosiery (these may need to be temporarily removed to facilitate further examination).

ONGOING CARE, MONITORING AND SUPPORT

  • Upon completion of the ABCDE leave the patient comfortable
  • If vital signs are abnormal, it may be appropriate to leave electronic monitoring equipment attached.
    Rationale – To evaluate the efficacy of  interventions and/or treatments delivered during the initial assessment. 
  • Consider repeating ABCDE assessment to re-assess the patient.
    Rationale – To evaluate the efficacy of  interventions and/or treatments delivered during the initial assessment.  
  • Reports findings according to NEWS2 escalation guidance and local policy using a structured communication tool e.g., Introduction, Situation, Background, Assessment, Recommendation, Decision.  
    Rationale – To facilitate effective communication with other members of the multi-disciplinary team.

DOCUMENTATION

Document the issues and intervention in the patient’s nursing notes and include:
  • Record vital signs measured during the ABCDE assessment on the NEWS2 chart or equivalent.
  • If using a paper chart (rather than an electronic system), calculate the aggregate NEWS2 and take note of the patient’s risk level.
  • Document other ABCDE findings according to local policy.

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