B for Breathing

Assess the patient's breathing rate, depth, and pattern. Listen for any abnormal sounds and check oxygen saturation levels.

As nurses we look at both, the mechanical act of breathing (how the lungs and chest wall are moving) and the effectiveness of that breathing (how well oxygen is being delivered to the body).

Observation:

We begin by observing the patient's chest and abdomen for any signs of respiratory effort. This includes looking for chest movements to see if they are symmetrical and noting any use of accessory muscles (like the neck muscles) which might indicate respiratory distress.
We need to also check for nasal flaring (widen nostrils), pursed-lip breathing (breathing by making a small opening with the lips), or cyanosis (a bluish discolouration of the skin, especially around the lips and fingertips).

Rate:

We count the respiratory rate, noting if it's too fast (tachypnea) or too slow (bradypnea). The normal respiratory rate for adults is typically 12-20 breaths per minute. We usually do this check during Obs (observations).

Rhythm and Depth:

We assess the rhythm of the breaths to see if they are regular or irregular. We also check the depth of each breath, noting if they are shallow or deep.

Auscultation:

We use a stethoscope to listen to the patient's breath sounds in various parts of the chest and back. We are listening for normal breath sounds and any abnormal sounds like wheezing, crackles, or rhonchi. The absence of breath sounds in certain areas can also be significant. Note that we may not see many nurses do this test in England or use a stethoscope for that matter, however there is nothing stooping us from carrying this test.

Oxygen Saturation:

We will use a pulse oximeter to measure the patient's oxygen saturation. This device gives a percentage reading of how saturated the haemoglobin in the red blood cells is with oxygen. A reading below 96% in a resting person could be a cause for concern. Remember the NEWS 2 we discussed at the top.

Ask the Patient:

We need to ask the patient if they are experiencing any difficulty breathing or if they have any chest pain. We can also ask about any history of respiratory conditions or symptoms like coughing, wheezing, or sputum production.

Additional Assessments:

If the patient is on oxygen therapy, we should check the equipment to ensure it's delivering the correct amount of oxygen and functioning properly.
We should also check the colour and consistency of any sputum produced.

Immediate Interventions:

If any abnormalities are detected, we could elevate the head of the bed to make breathing easier, just make sure you ask for permission and make sure the patient can be moved (we do patient repositioning a lot in the wards), administer supplemental oxygen (but remember that O2 administration requires a prescription). In doubt call for additional assistance.

C for Circulation

We check the patient's pulse, blood pressure, and skin colour. We check that adequate blood flow is distributed to all parts of the body.

When we assess circulation, we are looking at both the mechanical function of the heart and the effectiveness of blood flow throughout the body.

Check the Pulse:

We start by feeling the patient's pulse, most of the time I use an electronic device called the "patient monitor", it may have other names, such as the Obs machine. We can also do this manually via the radial artery on the wrist. We pay attention to the rate, rhythm, and strength of the pulse. A rapid or slow pulse can indicate a circulatory problem. Remember the NEWS 2 we discussed at the top.

Blood Pressure:

In my experience we measure the patient's blood pressure using a monitor machine, however we can also use a sphygmomanometer. A reading that's too high or too low can provide insights into potential circulatory issues.

Capillary Refill:

We press down on one of the patient's fingernails or toenails until it turns white and then release. I observe how quickly the colour returns. A delay in the return of colour (more than 2 seconds) can suggest poor peripheral circulation.

Skin Temperature and Color:

We check the temperature of the patient's skin by feeling it with the back of my hand. Cold or clammy skin can be a sign of poor circulation. I also look for any signs of pallor (pale skin), cyanosis (blue skin), or mottling (red spots), which can indicate circulatory issues.

Heart Sounds:

Using a stethoscope, we listen to the heart sounds. We are listening for any irregularities, murmurs, or other abnormal sounds that might indicate a cardiac issue. Note that we may not see many nurses do this on the NHS.

Check for Peripheral Oedema:

We examine the patient's legs and ankles for any swelling. Peripheral oedema can be a sign of heart failure or other circulatory problems.

Ask the Patient:

We ask the patient if they have experienced any chest pain, palpitations, or shortness of breath. These symptoms can be indicative of circulatory or cardiac issues.

Immediate Interventions:

If we detect any abnormalities during our assessment, we could elevate the patient's legs to improve venous return (we ask for patient's permission and make sure he can move hid/her legs first), administer medications (as prescribed), or call for assistance.

D for Disability

Evaluate the patient's level of consciousness and neurological function.

Level of Consciousness:

In my own experience, if I was working on a fast paced environment, like the A&E department then I would use AVPU Scale to check for consciousness, if I was working on a ward I would most likely use GCS, read below to see why:

  AVPU Scale:

We use the AVPU scale to quickly assess the patient's level of consciousness. AVPU stands for:

This method provides us with a rapid assessment of the patient's neurological status, especially in emergency situations.

  Glasgow Coma Scale (GCS):

If a more detailed assessment of the patient's neurological status is required, we use the Glasgow Coma Scale (GCS). The GCS evaluates three aspects of a patient's responsiveness:


The scores from each category are summed to give a total score ranging from 3 (deep unconsciousness) to 15 (fully alert and oriented). This scale provides a comprehensive assessment of the patient's level of consciousness and can help guide further medical interventions. And don't worry, there is a piece of paperwork you need to fill in when you conduct GCS, you can use this as guidance.

Pupil Check:

We examine the patient's pupils to ensure they are equal in size and reactive to light. Any changes in pupil size or reactivity can indicate a neurological issue. Interestingly, sometimes GCS will include this check as part of the paperwork.

Blood Glucose:

We check the patient's blood glucose levels using a glucometer. Abnormal blood glucose levels, either too high (hyperglycemia) or too low (hypoglycemia), can affect the patient's level of consciousness and overall neurological function.
On the NHS, a healthy target, before meals, is typically between 4-7 mmol/L. However, do not worry, we all have to complete mandatory training before we can measure glucose levels.

Signs of Stroke:

We look for any signs of a potential stroke, such as facial drooping, arm weakness, or speech difficulties. If we suspect a stroke, we act quickly to ensure the patient receives the necessary medical attention.

Seizure Activity:

We monitor for any signs of seizures or postictal state (aftermath signs). If the patient has a history of seizures or is at risk, we ensure that they are in a safe environment to prevent injury, for example there is a bed rail check I have to complete every time I admit a patient, the bed rails keep the person safe inside the bed.

Ask the Patient:

If the patient is responsive, we ask them about any changes in their vision, sensation, or strength. We also inquire about any headaches, dizziness, or other neurological symptoms they might be experiencing.

Immediate Interventions:

If we detect any abnormalities during our assessment, we might elevate the head of the bed to reduce intra-cranial pressure (but we make sure we informed the patient first and we also make sure the patient can move that way), administer medications as prescribed, or call for assistance.

E for Exposure

We inspect the patient's skin and body for any injuries, rashes, or other abnormalities. We check that they are appropriately covered to maintain body temperature.

Our focus is on identifying and addressing any external factors or injuries that might be affecting the patient.

Undress the Patient as Necessary:

We carefully remove or adjust the patient's clothing to fully examine their skin. This allows us to identify any injuries, rashes, or other abnormalities that might not be immediately visible. I usually let the person do the undressing (if possible), and I do it bit by bit, re-dressing the section I just finished the exam, I do this because I don't want the patients to get could, and also to respect their dignity.

Check for Signs of External Injury:

We look for any cuts, bruises, burns, or other injuries on the skin. We also palpate gently to feel for any tenderness, swelling, or deformities.
It is essential we don't miss any possible pressure ulcers, this is very, very important.

Assess Skin Temperature and Colour:

We touch the patient's skin to check its temperature, ensuring it's neither too hot nor too cold. We also observe the skin's colour, looking for signs of pallor (pale), cyanosis (blue skin), or mottling (red spots), which can indicate circulatory issues.

Look for Rashes or Allergic Reactions:

We inspect the skin for any rashes, hives (raised rash), or signs of allergic reactions. This can help us identify potential allergens or underlying conditions.

Maintain Body Temperature:

We ensure the patient is kept warm, especially if they are exposed for an extended period. Hypothermia can be a risk, especially in patients who are immobile or in shock. We use blankets or warming devices as necessary.

Immediate Interventions:

If we identify any issues during our exposure assessment, we take appropriate measures. This might include dressing wounds, administering medications, or calling for additional medical assistance. As an additional tip, nurses are free to prescribe barrier creams, this is the easiest way to get signed off some proficiencies regarding decision making in PARE.

Documentation:

After conducting our assessment and implementing any necessary interventions, it's crucial that we meticulously document our findings and actions. For example if we are allowed, we must write the findings about pressure ulcers, this is usually done on the computer when required, and twice a day on the bedside folder.

The Following are some videos I found very useful to understand and review A to E assessments.