A Airway Look Listen Feel For any signs of airway obstruction. For noisy breathing e.g. gurgling, For the presence of air movement. For evidence of mouth/neck/swelling/haematoma. snoring or stridor. For security of artificial airway. For security of artificial airway. B Breathing Look Listen Feel At the chest wall movement, to see if it is normal and symmetrical. To the patient talking to see if they For the position of the trachea to To see if the patient is using their neck and shoulder muscles to can complete full sentences. see if it is central. breathe (accessory muscles). For noisy breathing e.g. stridor, For the surgical emphysema or At the patient to measure their respiratory rate. wheezing. crepitus. If the patient is diaphoretic (sweaty). C Circulation Look Listen Feel At the skin colour for pallor and peripheral cyanosis. To the patient for complaints of Your patient’s hands and feet to At the capillary refill time. dizziness and headaches. see if they are warm or cold. At the patient’s central venous pressure and jugular venous For patient’s blood pressure and heart Your patient’s peripheral pulses pressure. sounds. for presence, rate, quality, regularity and equality. D Disability Look Listen Feel At the level of consciousness. To patients response to external For patient’s response to external For facial symmetry, abnormal movements, seizure activity or stimuli and pain. stimuli. absent limb movements. For slurred speech. For muscle power and strength. At pupil size, equality and reaction to light. For patient’s orientation to person, place and time. E Exposure Look Listen Feel For any bleeding e.g. investigate wounds and drains that may be For air leaks in drains. The patient’s abdomen. hidden by bed clothes. For bowel sounds. F Fluids Look Listen Feel At the observation and fluid charts, noting the fluid input and For patient’s complaints of thirst. The skin turgor. output. At losses from all drains and tubes. At the amount and colour of the patient’s urine and urinalysis results. G Glucose Look Listen Feel At blood glucose levels. For patient’s complaints of thirst. If the patient is diaphoretic For signs of low glucose, including confusion and decreased For patient’s orientation to person, (sweaty, cold or clammy). conscious state. time and place. At medication chart for insulin and oral hypoglycaemics. Give oxygen Based on your assessment (above) decide on an appropriate oxygen flow rate or percentage. If in doubt commence on 4L/min on a Hudson mask and increase as indicated by oxygen saturation or patient condition Position your Position your patient to optimise their breathing – usually this is as upright position as possible and as tolerated by the patient. patient Place the patient in the left lateral position if they are unconscious but have adequate breathing and circulation and where there is no evidence of spinal injury. Call for help if you Establish IV if not present, +/- fluids. can’t manage Never leave a Document and communicate clearly: deteriorating All treatments provided. patient without a Outcomes of treatment implemented. priority management and What care is still required. review plan The plan should include expected outcomes and when the patient will be reviewed again .