Essential critical care skills 2: assessing the patient

A structured, systematic assessment of a patient who is critically ill is fundamental to good patient care, management, and experience. The assessment process must include a comprehensive review of the patient’s physiological, sociological, psychological, and spiritual needs to identify and prioritize problems (Baid et al, 2016). The airway, breathing, circulation, disability, and exposure (ABCDE) approach is a well-established, reliable assessment tool used in the systematic assessment of critically ill patients to prioritize and treat life-threatening clinical problems. Information from this should be communicated, escalated, and actioned as appropriate (Baid et al, 2016).

Early recognition of a deteriorating patient, together with a structured response and appropriate escalation, can reduce patient harm and the risk of adverse events (Massey et al, 2017). The critical care nurse makes a systematic assessment of the patient on admission, after shift handover, and in response to clinical deterioration (Baid et al, 2016). This article – the second in a seven-part series on critical care – will outline how to make a systematic assessment of a patient who is critically ill, using the ABCDE approach.

Airway

Once personal and patient safety is established, an airway assessment is the first stage in the ABCDE systematic approach. This is to assess airway patency, checking for signs of full or partial airway obstruction (Cathala and Moorley, 2020). A patient who can talk in a normal voice and full sentences has an airway that is patent. Box 1 lists the causes of airway obstruction.

Physical assessment of an airway involves the ‘look, listen and feel’ approach. Appropriate infection control measures should be followed to reduce the risk of contamination, for example, when caring for patients with Covid-19. The clinical signs of partial airway obstruction include:

• ‘See-saw’ respirations, seen as paradoxical chest and abdominal movements;

• Decreased air entry on chest auscultation using a stethoscope;

• Abnormal breath sounds (noisy breathing such as stridor involving a high-pitched sound, wheezing, or snoring);

• Use of accessory muscles;

• Inability to speak;

• Altered respiratory effort.