A-E Assessment in Nursing Practice

• Nursing practice for health complexity involves an A-E assessment.

Prepare Environment

• Maintain clinical standards for safety and quality.
• Actions involve washing hands, putting on gloves, and checking the bed area for necessary equipment (oxygen mask, suction, catheters, etc.).
• Suction equipment and oxygen flow meter should be available and in working order.
• Additional PPE includes a gown and protective glasses

Danger Assessment

• Always prioritize safety for yourself and others.
• Before approaching a patient, assess the scene for danger and potential risks.
• Only enter if safe and reassess danger while managing the patient.
• Check for danger, considering information from other staff and observations.
• Note any change including patient delirium, aggression, weapons, needles, drug paraphernalia, blood, vomit, urine, or faeces

Response Assessment

• Use the AVPU scale to determine the patient's level of consciousness.
• AVPU identifies the patient's level of consciousness: Alert, Voice, Pain, Unresponsive.
• Alert: Patient acknowledges you by looking, watching movements, or speaking.
• If not alert, speak loudly and clearly: "Hello, my name is...". If they respond by opening their eyes, making purposeful movements, or answering, they RESPOND TO VOICE.
• If no response to voice, apply painful stimuli (trapezius pinch on head). If they respond by opening their eyes, making movements, or answering, they RESPOND TO PAIN.
• If the patient is not alert and does not respond to voice or pain, they are considered UNCONSCIOUS.

Airway Assessment

• Assess the patient's airway and C-Spine.
• An obstructed airway leads to hypoxia and respiratory arrest.
• Recognize partial obstructions by identifying stridor (laryngeal narrowing).
• Clearing the airway involves asking the patient to cough or spit if conscious.
• If unconscious, airway management dictates OPA insertion. If c-spine injury is suspected, use a jaw thrust.
• With spinal precautions, ensure the cervical collar is secure and the patient is supine.
• Shoulders and pelvic crests should not be rotated, arms and legs straight.
• Assessing a patent airway involves looking inside the mouth for deformity, vomit, burns, tongue obstruction, missing teeth, oedema, stridor and/or patient is talking
• If any issues are identified, clear the airway immediately, e.g., Yankeur sucker with wall suction.

Breathing Assessment

• Assess patient's breathing to determine if they are breathing or not.
• If unconscious and not breathing, begin resuscitation and follow Basic Life Support (BLS).
• Check respiratory rate and oxygen saturation level and breathing characteristics: unremarkable, shallow, deep, rapid, or slow.
• Advanced Life Support (ALS) algorithm may be necessary.
• Record lung auscultation air entry and note if L=R, L>R, or L0. or Pale or white, Flushed (red), Mottled (blotchy), Cyanotic, or Jaundice.
• Check whether the patient requires oxygen.

Circulation Assessment

• Circulation assessment is a quick evaluation of the patient's skin and radial pulse.
• Assess radial or brachial pulse for: unremarkable, regular, irregular (arrhythmia), slow (bradycardia), rapid (tachycardia), strong, weak, not palpable.
• Assess skin circulation: unremarkable, warm/hot, cool/cold, dry, moist/clammy.
• The patient will be on continuous cardiac monitoring to assess cardiac rhythm.
• Record the patient's pulse, BP, body temperature, and cardiac rhythm along with IV cannula presence.

Disability, Environment, and Exposure Assessment

• Assess the patient using the Glasgow Coma Scale (GCS) for impaired consciousness by eye opening, verbal response, and motor response.
• Assess arms and legs and GCS total.
• Ensure spinal precautions are used accordingly.
• Pupils will be assesed for shape and reaction.
• Patient must remain warm, expose in staged manner, and blankets be applied
• Check for abnormalities like cellulitis or rash.
• Check BGL and pain score and record.
• Complete the Adult Triage Nursing Assessment form, including patient details, date, time, and signature.