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Wednesday, May 16, 2012
Assess ability to take a deep breath
Assess ability to speak in a full sentence – can the patient speak a full sentences, juse phrases, single words, or not at all
Assess if the airway is clear
Look, listen and feel for the movement of air
Assess the adequacy of the breathing process – is their sufficient rate and volume of air being moved?
Assess work of breathing (patient effort versus efficacy)
Listen to the chest (through Auscultation) and identify any variances of normal breathing. Normal breathing should sound like soft air movements; absent breath sounds is very bad; wheezes suggests bronchospasm; crackles and rales indicates pulomonary oedema or infection.
Expose chest (while maintaining patient’s dignity) and assess for accessesory muscle involvement, such as sternocloidomastoid arching, pectoral muscles,external and internal intercostal muscles, which are all signs of increased respiratory distress
Examine for life- threatening haemorrhage
Assess perfusion (level of consciousness, skin colour, pulse rate and blood preasure
Assess the pule mannually – is it regular or irregular, what is the rate (15 seconds x 4), skin colour, temperature, central and peripheral cap refil.
Measure level of consciousness (AVPU – Patient is Alert, responding to verbal stimuli, responds to pain, unconscious; GCS: Glascow Coma Score)
Check pupil size and functioning response (make sure you document pupil size)
Assess motor and sensory responses to all four limbs.
Assess ability to walk
Assess ability to smile
Exposure and Environment
Expose the patient (while maintaining their dignity) so that you can see any injuries, watch breathing, etc.
Look for a rash, wounds, contusions
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