{"id":274,"date":"2015-02-17T19:05:55","date_gmt":"2015-02-17T19:05:55","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=274"},"modified":"2021-05-20T19:53:32","modified_gmt":"2021-05-20T19:53:32","slug":"2-2-emergency-assessment-checklist","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/2-2-emergency-assessment-checklist\/","title":{"raw":"2.6 Initial and Emergency Assessment","rendered":"2.6 Initial and Emergency Assessment"},"content":{"raw":"The ABCCS assessment (airway, breathing, circulation, consciousness, safety) is the first assessment you will do when you meet your patient. This assessment is repeated whenever you suspect or recognize that your patient\u2019s status has become, or is becoming, unstable.\r\n\r\nFor example, if you assess that your\u00a0patient is short of breath (dyspneic) with an increased respiration rate\u00a0(tachypneic), then you should proceed with an ABCCS assessment and a focused respiratory assessment with appropriate interventions.\r\n\r\nThe ABCCS assessment includes the steps in Checklist 18.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 18: Initial and Emergency Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

A \u2013 Airway\r\n
    \r\n \t
  • Is the patient\u2019s airway compromised?<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Does the patient\u2019s position need to be changed?\r\n\r\nIf\u00a0patient is choking on thick secretions, consider oral suctioning (check suction equipment).<\/td>\r\n<\/tr>\r\n
B \u2013 Breathing\r\n
    \r\n \t
  • Assess rate and ease of breathing.<\/li>\r\n \t
  • Assess the effectiveness of the oxygen delivery.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Is the oxygen flow connection intact?\u00a0Is the rate, flow, and percentage as ordered?\r\n\r\nBased on your assessment, consider the need for potential oxygen supplementation.<\/td>\r\n<\/tr>\r\n
C \u2013 Circulation\r\n
    \r\n \t
  • Assess for the presence of a radial pulse.<\/li>\r\n \t
  • Assess skin colour, moisture, and temperature for signs of decreased tissue perfusion (pale, dusky, cool, or clammy skin).<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Note whether the pulse is too fast, too slow, or absent.\r\n\r\nIf a radial pulse is not detectable, check for a carotid pulse.\r\n\r\nIf no pulse is present, call for help and start CPR.<\/td>\r\n<\/tr>\r\n
C \u2013 Consciousness\r\n
    \r\n \t
  • Check the patient\u2019s level of consciousness (LOC).<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Is the patient alert, drowsy, disoriented, restless, agitated, unconscious?\r\n\r\nNote if there is a change from the patient\u2019s normal or previously noted LOC.<\/td>\r\n<\/tr>\r\n
S \u2013 Safety\r\n
    \r\n \t
  • Ensure the patient is safe and free from risk of harm or injury at all times.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Check for name band and allergy band.\r\n\r\nCheck oxygen saturation level.\r\n\r\nCheck that suction is working.\r\n\r\nCheck brakes on the bed, bedrail position (up, if required), bed is at the appropriate level, and call bell is within reach.\r\n\r\nAre there any fall risk indicators?\r\n\r\nAre there any dysphagia (difficulty swallowing) guidelines, or should there be some requested?<\/td>\r\n<\/tr>\r\n
Report and document assessment findings and related health problems according to agency policy.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
\r\n

Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n

\r\n
    \r\n \t
  1. Initial assessment of your patient\u00a0reveals that the patient is having trouble speaking. What would be your next steps?<\/li>\r\n \t
  2. What is included in the safety check on your unit? Is there anything that is not listed here?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>","rendered":"

    The ABCCS assessment (airway, breathing, circulation, consciousness, safety) is the first assessment you will do when you meet your patient. This assessment is repeated whenever you suspect or recognize that your patient\u2019s status has become, or is becoming, unstable.<\/p>\n

    For example, if you assess that your\u00a0patient is short of breath (dyspneic) with an increased respiration rate\u00a0(tachypneic), then you should proceed with an ABCCS assessment and a focused respiratory assessment with appropriate interventions.<\/p>\n

    The ABCCS assessment includes the steps in Checklist 18.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 18: Initial and Emergency Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/span><\/h5>\n<\/td>\n<\/tr>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    \u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    A \u2013 Airway<\/p>\n
      \n
    • Is the patient\u2019s airway compromised?<\/li>\n<\/ul>\n<\/td>\n
    		Does the patient\u2019s position need to be changed?<\/p>\n

    If\u00a0patient is choking on thick secretions, consider oral suctioning (check suction equipment).<\/td>\n<\/tr>\n

    B \u2013 Breathing<\/p>\n
      \n
    • Assess rate and ease of breathing.<\/li>\n
    • Assess the effectiveness of the oxygen delivery.<\/li>\n<\/ul>\n<\/td>\n
    		Is the oxygen flow connection intact?\u00a0Is the rate, flow, and percentage as ordered?<\/p>\n

    Based on your assessment, consider the need for potential oxygen supplementation.<\/td>\n<\/tr>\n

    C \u2013 Circulation<\/p>\n
      \n
    • Assess for the presence of a radial pulse.<\/li>\n
    • Assess skin colour, moisture, and temperature for signs of decreased tissue perfusion (pale, dusky, cool, or clammy skin).<\/li>\n<\/ul>\n<\/td>\n
    		Note whether the pulse is too fast, too slow, or absent.<\/p>\n

    If a radial pulse is not detectable, check for a carotid pulse.<\/p>\n

    If no pulse is present, call for help and start CPR.<\/td>\n<\/tr>\n

    C \u2013 Consciousness<\/p>\n
      \n
    • Check the patient\u2019s level of consciousness (LOC).<\/li>\n<\/ul>\n<\/td>\n
    		Is the patient alert, drowsy, disoriented, restless, agitated, unconscious?<\/p>\n

    Note if there is a change from the patient\u2019s normal or previously noted LOC.<\/td>\n<\/tr>\n

    S \u2013 Safety<\/p>\n
      \n
    • Ensure the patient is safe and free from risk of harm or injury at all times.<\/li>\n<\/ul>\n<\/td>\n
    		Check for name band and allergy band.<\/p>\n

    Check oxygen saturation level.<\/p>\n

    Check that suction is working.<\/p>\n

    Check brakes on the bed, bedrail position (up, if required), bed is at the appropriate level, and call bell is within reach.<\/p>\n

    Are there any fall risk indicators?<\/p>\n

    Are there any dysphagia (difficulty swallowing) guidelines, or should there be some requested?<\/td>\n<\/tr>\n

    Report and document assessment findings and related health problems according to agency policy.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
    \n
    \n

    Critical Thinking Exercises<\/p>\n<\/header>\n

    \n
      \n
    1. Initial assessment of your patient\u00a0reveals that the patient is having trouble speaking. What would be your next steps?<\/li>\n
    2. What is included in the safety check on your unit? Is there anything that is not listed here?<\/li>\n<\/ol>\n<\/div>\n<\/div>\n","protected":false},"author":5,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-274","chapter","type-chapter","status-publish","hentry"],"part":253,"_links":{"self":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/274","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/users\/5"}],"version-history":[{"count":25,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/274\/revisions"}],"predecessor-version":[{"id":10115,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/274\/revisions\/10115"}],"part":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/parts\/253"}],"metadata":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapters\/274\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/media?parent=274"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/pressbooks\/v2\/chapter-type?post=274"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/contributor?post=274"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/opentextbc.ca\/clinicalskills\/wp-json\/wp\/v2\/license?post=274"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}