Key Questions - The acutely ill patient

Phil Jevon, RN, BSc, is honorary clinical lecturer and resuscitation officer/clinical skills lead, Manor Hospital, Walsall.

Prompt assessment and accurate diagnosis is vital in acutely ill patients. It is important to follow a systematic and logical approach when assessing this group of patients. This approach should encompass airway, breathing, circulation, disability and exposure (ABCDE). The emphasis is on calling for help early; completing an initial assessment and re-assessing regularly; treating life-threatening problems first before proceeding to the next part of the assessment; and assessing the effects of any treatment.

Does the patient have a clear airway?

Assess if the patient is able to talk, for signs of air entry at the mouth and whether there are any signs of partial upper airway obstruction.

For example, this might be: snoring (usually caused by the tongue blocking the airway); gurgling (due to the presence of fluid such as secretions or vomit in the mouth or upper airway); stridor (usually due to either a foreign body in the airway or laryngeal oedema); and wheeze (due to bronchospasm). Look for cyanosis (late sign of a compromised airway).

If the patient is able to talk and there are no abnormal breath sounds she or he has a clear airway. Signs of a compromised airway include reduced air entry and abnormal breath sounds (such as snoring, gurgling, stridor or wheeze). If the patient has complete airway obstruction there will be no air entry, no breath sounds and she or he will not be able to talk.

Is the patient’s breathing compromised?

Evaluate efficacy of breathing, work of breathing and adequacy of ventilation:

• Efficacy of breathing: air entry, chest movement, pulse oximetry, arterial blood gas analysis and capnography;

• Work of breathing: respiratory rate and accessory muscle use, for example, neck and abdominal muscles;

• Adequacy of ventilation: heart rate, skin colour and mental status.

Signs that a patient’s breathing is compromised include: tachypnoea; cyanosis; use of accessory respiratory muscles; the presence of abnormal breath sounds (such as wheeze); altered conscious level and difficulty completing sentences in one breath.

Is the patient’s circulation compromised?

Palpate peripheral pulses for presence, rate, quality, regularity and equality. Check blood pressure and for signs of adequate perfusion, for example, colour, temperature, capillary refill time, conscious level and urine output. Look for signs of blood loss.

Signs that a patient’s circulation is compromised include: tachycardia; hypotension; poor peripheral perfusion; altered consciousness level; and deteriorating urine output.

Is the patient’s level of consciousness compromised?

Talk to the patient and elicit a response. Evaluate level of consciousness, initially using the AVPU scale. Check both pupils and compare size, equality and reaction to light and perform bedside glucose measurement to exclude hypoglycaemia. It may also be necessary to perform an assessment using the Glasgow Coma Scale.

Check the patient’s drug chart for any recent administration of medication that may affect consciousness level.

Signs that a patient’s level of consciousness may be compromised include confusion, an abnormal AVPU and/or GCS reading or abnormal pupils/pupilary reactions.

Has the patient had a cardiopulmonary arrest?

Gently shake the patient’s shoulders and ask her or him: ‘Are you alright?’ If there is no response, call out for help, turn the patient onto their back, open the airway using the head tilt/chin lift and, after clearing the mouth if necessary, look, listen and feel for no longer than 10 seconds to establish whether the patient is breathing normally (personnel trained and experienced in assessing critically ill patients will perform a simultaneous carotid pulse check).

Signs of a cardiopulmonary arrest are: unconsciousness; not breathing normally (an occasional gasp, laboured or noisy breathing is not normal); no pulse; and no signs of life.

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