A-E Assessment
- Created by: Hannahshelly
- Created on: 31-03-20 10:36
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- A-E Assessment
- Rationale
- Systamatic
- Reduces the risk of miscommunication
- Standardisedapproach across multi-professional teams
- Infants and children
- Look well for a long time before the body ‘gives up’ and they deteriorate rapidly. If treatment is started before deterioration it is far more successful
- The News2 and Pews are tools used to document and monitor trends
- The condition of an unwell patient can change rapidly which is why it is important to perform a baseline assessment
- Frequency of assessment must be decided - based on the score
- Should be regularly monitored, can recognise changes, assess intervention and respond rapidly to deterioration
- Airway
- What is the positioning and basic manoeuvres?
- Anything visible in the mouth?
- Listen and feel for air movement
- Is the patient conscious and vocalising? This is indication of a patent (clear) airway
- Open the airway
- Mucous membranes should look pink and moist
- Blush tinge is a sign of reduced oxygen in the blood
- Obstruction can happen at any level of respiratory tract
- Differences in a child
- Proportionately larger head
- So can block airway by the position of their heads
- Infants are obligate nose breather
- Larger more flaccid tongue
- Larynx more superior and anterior
- Proportionately larger occiput
- Loosely attached mucous membrane
- Infants and young children rely on the diaphragm to breathe more than adults do
- Cricoid cartilage narrowest part of the funnel shape airway
- Proportionately larger head
- Airway Assessment
- Feel for inspiration
- Listen for noise breathing
- Stridor - inspiratory noise; airway obstruction above the thoracic inlet
- Wheeze - expiratory noise; airway obstruction below the thoracic inlet
- Grunting - expiratory noise; attempt to maintain the end-expiratory lung volume (infants and children)
- Snoring - the tongue is partially obstructing the pharynx
- If completely obstructed then there will be no breath sounds or noise
- Partial obstruction - air entry is diminished and often noisy as air pass through narrowed airway or past foreign onbject
- Other causes
- Secretions
- Blood
- Vomit
- Food
- Loose teeth/dentures
- Foreign objects
- Facial burns
- Inhalation injury
- Oedma
- Anaphylaxis
- Visual assessment - split second by looking at them
- Skin tone
- Engaging with the enviroment
- Obviously breathing?
- Using all limbs?
- Screaming/crying?
- Interaction between parent and child
- Age?
- Breathing
- Visual Inspection
- Look, listen and feel, what is their position
- Advanced Skills
- Auscultation-is using a stethoscope to listen to sounds of breathing
- Palpatation - using your hands, check for equal chest movements and that the trachea is midline
- Perfusion - tapping on a surface to determine the underlying structures eg consolidation, collapse or fluid
- Respiratory rate is the most useful indicator to assess if the airway is compromised
- Adults increased respiratory rate of >20 bpm is a warning that they could suddenly deteriorate
- Under 16 bpm
- 0-1 40-60bpm
- 1-5 20-40bpm
- 5-12 20-40 bpm
- Over 12 15-25bpm
- Persistently high respiratory rates may lead to respiratory fatigue and failure
- Low respiratory rates can be a pre-morbid sign
- Breathing Assessment
- Is respiratory rates within parameters?
- Rhythm altered
- Tripod position
- Use of accessory muscles
- Pursed lip breathing
- Mouth breathing/nasal flaring
- Unequal lung expansion
- Child Assessment
- Tachypnoea
- Nasal flaring
- Head bobbing
- Intercostal recession
- Subcostal recession
- Trachea tug
- Additional sounds
- Exhaustion
- Visual Inspection
- Circulation
- Heart Rate
- Tachycardia is faster than age parameters
- Bradycardia is slower than age parameters
- Irregular rhythm suggest cardiac arrhythmia
- Inaqualitieto certain areas could suggest localisted circulatory impairment eg clots
- Blood Pressure
- Pulse Pressure
- Weak and thread pulse indicates reduce cardiac output and shock
- Bounding indicates increased cardiac output for example sepsis
- Perfusion
- Assesses skin colour and tempreture
- Pale skin (pallor) and mottling can be due to shock
- Blood is diverted from peripheries to preserve blood supply to vital organs
- Cyanosis is a blush tinge to the skin which indicates lack of oxygenation
- Red, pink, flushed skin +/- rashes may indicate sepsis
- Pale or ashen skin can be due to anaemia
- A reduction of the amount of haemoglobin in the blood
- Capillary Refill Time
- Heart Rate
- Rationale
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