25/12/2024
ABCDE - RESPIRATORY ASSESSMENT
ABCDE: Stands for Airway, Breathing, Circulation, Disability, and Exposure.
Purpose: Used for assessing respiratory patients and critically ill/deteriorating patients.
Goal: Prioritize life-threatening conditions and ensure initial management.
A - AIRWAY
Check if airway is natural or artificial.
Main artificial airways:
Nasopharyngeal: Tube in the nasal passage.
Oropharyngeal: Tube in the mouth.
Tracheostomy: Tube inserted via the neck into the windpipe.
B – BREATHING
Assess ventilation mode, PEEP, ASB, respiratory rate, SpO2, FiO2, tidal volume, ABGs, chest X-ray results, and auscultation.
Respiratory Rate (RR): Normal for adults ~12 breaths/min.
SpO2 (Oxygen Saturation): Normal 95–98% for healthy individuals.
FiO2: Oxygen concentration inhaled (e.g., room air is 21%).
ABGs: Analyze arterial blood gases for detailed oxygenation levels.
Chest X-rays: Identify lung abnormalities.
Auscultation: Use stethoscope to listen to lung sounds.(normal, wheeze, crackles, absent).
C - CIRCULATION
Evaluate heart rate, blood pressure, temperature, infusions, urine output, and CVVH if applicable.
Continuous Veno-Venous Hemofiltration (CVVH): Temporary renal failure treatment for unstable patients unable to tolerate hemodialysis.
D – DISABILITY
Assess sedation score, Glasgow Coma Scale (GCS), pupil reactions, intracranial pressure (ICP), and presence of an external ventricular drain (EVD).
Sedation Score: Commonly uses RASS (-5: unrousable, +5: combative).
GCS: Measures consciousness (eye, verbal, motor responses).
ICP: Monitored when EVD is present.
E - EXPOSURE
Perform a full body assessment for hidden signs of respiratory compromise:
Inspect for chest trauma, scars, or deformities.
Monitor temperature for signs of infection.
