ABCDE

Question 1

Airway
look

Answer 1

• Type of airway
• are they self ventilating?
• artificial?
• is the airway patent?

Question 2

airway listen

Answer 2

• stridor
• gurgling
• wheeze
• snoring
• no sound

Question 3

airway feel

Answer 3

air movement

Question 4

breathing look

Answer 4

• colour
• mode of ventilation
• respiratory rate
• Sp02 and Fi02
• pattern of breathing
• expansion of chest
• accessory muscle use
• sputum
• ABGs
• CXRs

Question 5

breathing listen

Answer 5

• able to speak?
• auscultation
• cough
• percussion note
• auscultation - stethoscope

Question 6

breathing feel

Answer 6

• chest wall movement
• apical
• diaphramatic
• expansion
• tactile fremitus

Question 7

circulation look

Answer 7

• colour
• HR and rhythm
• BP on a machine
• CRT
• core temp
• urine output and colour
• fluid balance
• limb odema

Question 8

circulation listen

Answer 8

blood pressure manually

Question 9

circulation feel

Answer 9

• pulse
• HR
• strength and regularity
• skin temp
• assess for pitting odema

Question 10

disability look

Answer 10

• level of conciousness
• ACVPU (alert, confusion, voice, pain, unresponsive)
• GCS (glasgow coma scale)
• RASS (richmond agitation-sedation score)
• pupils
• blood sugars

Question 11

disability sound

Answer 11

• verbal responses
• agitation
• pain? VAS

Question 12

exposure look

Answer 12

• patient position
• muscle wasting
• wounds/dressing
• signs of infection, bleeding
• finger clubbing
• nicotine stains
• mobility aids
• general condition of patient

Question 13

exposure listen

Answer 13

• chest drains- bubbling
• alarms- what are they

Question 14

exposure feel

Answer 14

• skin tempreture
• ROM/muscle strength if applicable