Assessment ABCDE

Assessment Steps (20 Minutes)
Key here to follow ABCDE of NEWS chart verbalise the ndings

loudly, document observations on NEWS or GCS chart accurately.
• 🟣 🟣 Read your scenario in detail Know the patient name, presenting complaints, past history, social
history, medication patient currently taking. ( you may have to clearly sometimes it may be o 2 full
pages)🟣 🟣
• Check the equipments BP machine, pulse oximetry, thermometer, know how to use them before start
• Check the paperwork you need to ll in, NEWS, GCS or community Observation chart you only get one
of them
• Speak up clearly and verbalise things loudly (please do not forget to refer back to the patient scenario
page)
Airway:
1. Check & verbalise that seen is safe to enter, perform hand hygiene using alcogel (demonstrate proper
hand hygiene using alcogel)
2. Introduce self and explain the purpose (I am ….I am here to assess you to provide appropriate care, get
help and also to plan the care. Ask for consent is it ok for me to assess you? Or can I continue?
3. Provide privacy by asking & closing curtains and clean hands using alcogel. Ask patient about his
condition how he feels now? (Example what brought you in today? How’s the condition or how are you
feeling now?)
4. Check comfort, position and Are you comfortable? Assess pain using 1-10 scale, Check whether they
need to be positioned properly?
5. Can I check your ID? Perform ID check with ***patient document and ID band verbalise that it is
matching with the record****. (Check Name, DOB, Hosp Number or Address or Photo ID, Allergy)
***must verbalise that it matches with patient document & ID band****
6. Verbalise to the examiner that ***Airway is patent,*** no visual obstructions. Patient is talking to me
comfortably with no evidence of airway obstruction. If patient is on Oxygen ensure it is
working(verbalise) and patient is correctly wearing the mask.
Document in ABCDE paper (bullet points only for your reference )complaints and oxygen therapy -how
many litres of oxygen and device
Breathing
Check Respiratory rate say starting now, observe for full one minute, ensure you observe chest movement
intermittently.
Write the ndings Respiratory Rate into the ABCDE paper.
Verbalise Characteristics of Respiration as fast or slow (use the word characteristics of respiration is…..)
There is equal chest movement , check for any added noises. Wheezing, cough, look for work and pattern
of breathing use of accessory muscles. Verbalise to the examiner about chest movement and breathing
pattern. Verbalise the ndings if you don’t nd these verbalise that there no use of accessory muscles,
Pallor no cyanosis, no sweating, no see saw breathing.
Circulation
Do the BP, check which arm to use, select the right BP cu , apply the BP cu properly.
Check pulse oximetry, apply pulse oximetry to the nger, verbalising that nger is warm, no nail varnish.
Ensure BP machine is on, press the BP button.( check with the patient BP cu is working)
Document BP (Systolic and Diastolic) Oxygen Saturation …
Make a note of the pulse on the machine and verbalise that you will cross check manually.
Remove BP cu and pulse oximetry.
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Ask patient to put arm across the chest and count the pulse for 1 full minute, verbalise the pulse
characteristics as normal/ strong pulse etc. Document Pulse….
Check Urine Output
Disability
Assess- ACVPU
Verbalise that patient is alert, not confused or confused. If patient is confused ask for Time, place & person
to verify. Check whether it is ac acute confusion example head injury or chronic confusion example
Alzheimer’s disease.
Assess pain- ask patient whether he has a pain, location, and ask to rate in a scale of 0-10
Document in the paper
Check Blood Sugar ( this is a routine test must be carried out as patient show confusion or can go into
unconscious due to low blood sugar)
Exposure
Check Temperature using the given thermometer. Document temperature.
Verbalise that you complete the head to foot examination. Ask patient whether he/ she has rashes, wounds
observe the skin (no need to remove clothing just verbalise).
Obtain a medical history- ask for what other medical problems he has? Any medications is he on? Ask
about current problem, is it a recurrence or new problem.(it’s all in the scenario just need to follow the
pattern of asking from present, past, social, drug history and allergies.
✅ ✅ ✅ Document all ndings into the NEWS chart in the order ✅ ✅ ✅

1. Patient details
2. Date and time (scenario time)
3. Initial
4. Start from top down, document respiration, saturation on scale 1( scale 2 only used for COPD patient)
air, oxygen & device, BP both systolic and Diastolic, Pulse, Disability record Alert put A, Temperature.
5. Add the NEWS total and write the number in the right box
6. Write the monitoring frequency as per the score (Do not forget to check the single parameter)
7. Write the escalation plan
8. Cross check the NEWS chart ensuring all columns correctly lled in
Verbalise NEWS score and monitoring frequency and actions you would take based on the observation
ndings
***GCS chart ***(Follow the above A to E assessment) and additional Neuro Assessment to complete (Coma
Scale for GCS scoring), Pupil Assessment using pen torch, Limb assessment- assessing strength and
weakness of arms and legs.
Community Scenario (Follow the above A to E assessment and complete the below based on the scenario
Depression Scenario additional PHQ Questionnaire to complete and discuss the action
Community Assessment (Diabetes Scenario ) MUST chart to complete and discuss and verbalise the
action based on MUST score)
Alzheimer’s Disease CIT (6) chart to complete and discuss the action
***Go through Physical, Psychological, Spiritual and Sexual aspects

Physical -Assess mobility and ask questions how does he/ she mobilise
Eating and Drinking, Elimination (Urine & Bowel movement )***
Psychosocial - Does he live alone or who does he live with, any carers or pets to take care
Does he smoke, how many cigarettes? Discuss smoking cessation, does he drink alcohol?
Is the patient deteriorating and dying, assess the anxiety, support family, check patient wishes
Provide psychological support
Spiritual- Any spiritual belief or religion he follows? Does he need chaplain or priest visit?
Sexual- Any concerns on sexual health?
Health Skills Training Ltd U.K. Manchester, contact- 07711554472

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Assessment ABCDE

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Assessment Steps (20 Minutes)

Key here to follow ABCDE of NEWS chart verbalise the ndings

✅ ✅ ✅ Document all ndings into the NEWS chart in the order ✅ ✅ ✅

***Go through Physical, Psychological, Spiritual and Sexual aspects

Health Skills Training Ltd U.K. Manchester, contact- 07711554472

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