ABCDEFG Algorithm Look A Airway

Text Version- ABCDEFG Algorithm Look A Airway B Breathing C CirculationFor any signs of airway obstruction For evidence of mouth/neck/swelling/haematoma For security of artificial airway Look At the chest wall movement, to see if it is normal and symmetrical To see if the patient is using their neck and shoulder muscles to breathe (accessory muscles) At the patient to measure to measure their respiratory rate Look At the skin colour for pallor and peripheral cyanosis At the capillary refill time At the patient’s central venous pressure and jugular venous pressure Look At the level of consciousness For facial symmetry, abnormal movements, seizure activity or absent limb movements At pupil size, equality and reaction to light Listen For noisy breathing e. g. gurgling, snoring or stridor Feel For the presence of air movement For security of artificial airway Feel For the position of the trachea to see if it is central For surgical emphysema or crepitus If the patient is diaphoret ic (Sweaty) Listen To the patient talking to see if they can complete full sentences For noisy breathing e. g. stridor, wheezingListen To the patient for complaints of dizziness and headaches For patient’s blood pressure and heart sounds Feel Your patient’s hands and feet to see if they are warm or cold Your patient’s peripheral pulses for presence, rate, quality, regularity and equality. Feel For patient’s response to external stimuli For muscle power and strength D Disability Listen To patient’s response to external stimuli and pain For slurred speech For patient’s orientation to person, place and time. E F Exposure Fluids G Glucose Give oxygen Position your patient Call for help if you can’t manage Never leave a deteriorating patient without a priority management and review plan Look Listen Feel For any bleeding e. g. nvestigate wounds and drains For air leaks in drains The patients abdomen that may be hidden by bed clothes For bow el sounds Look Listen Feel At the observation and fluid charts, noting the fluid For patient’s complaints of thirst The skin turgor input and output At losses from all drains and tubes At the amount and colour of the patient’s urine and urinalysis results Look Listen Feel At blood glucose levels For patient’s complaints of thirst If the patient is diaphoretic, (sweaty, cold or clammy) For signs of low glucose, including confusion and For patient’s orientation to person, place and time decreased conscious state At medication chart for insulin and oral hypoglycaemics Based on your assessment (above) decide an appropriate oxygen flow rate or percentage.If in doubt commence on 4L/min on a Hudson mask and increase as indicated by oxygen saturation or patient condition. Position your patient to optimise their breathing-usually this is as upright position as possible and as tolerated by the patient. Place the patient in the left lateral position if they are unco nscious but have adequate breathing and circulation and where there is no evidence of spinal injury Establish IV If not present, +/- fluids Document and communicate clearly all treatment provided, outcomes of treatment implemented what care is still required The plan should include expected outcomes and when the patient will be reviewed again.