5.1 Patient Assessment Frameworks & The ABCDE Approach

Patient Assessment Frameworks & The ABCDE Approach

In UK clinical practice, systematic patient assessment is an essential core competency outlined in the Nursing and Midwifery Council (NMC) Standards of Proficiency for Registered Nurses (Platform 3: Assessing Needs and Planning Care). When assessing a patient, registered nurses must apply evidence-based frameworks to detect early signs of physiological decline, prioritize life-threatening emergencies, and establish accurate baselines for holistic care planning.

The ABCDE Assessment Framework

The Resuscitation Council UK (RCUK) advocates the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) for evaluating all acutely ill or deteriorating patients. The core principle of ABCDE is treat life-threatening problems as you find them before moving to the next parameter, re-evaluating continuously after any intervention.

Airway (A)

The primary objective is ensuring airway patency. Obstruction may be partial (stridor, snoring, gurgling) or complete (silent chest wall movement without air entry).

• Assessment: Look for chest and abdominal movement, listen for breath sounds or abnormal airway noises near the mouth, and feel for expired air on your cheek.
• Interventions: Perform head-tilt/chin-lift or jaw-thrust maneuvers; clear secretions using Yankauer suction under direct vision; insert an airway adjunct such as an oropharyngeal airway (Guedel) in unconscious patients lacking a gag reflex, or a nasopharyngeal airway (NPA) in semi-conscious patients. High-flow oxygen (15 L/min via a non-rebreather reservoir mask) must be administered immediately during acute resuscitation.

Breathing (B)

Assess adequacy of ventilation and oxygenation.

• Assessment: Count the exact respiratory rate for 60 seconds (normal: 12–20 breaths per minute; tachypnea >25 breaths/min is a key early sign of severe deterioration). Observe respiratory effort, accessory muscle use, tracheal position, chest symmetry, and pulse oximetry ($SpO_2$). Auscultate lungs for wheezes, crackles, or absent breath sounds.
• Interventions: Position patient upright unless contraindicated. Administer oxygen tailored to target saturations (94–98% for general patients, or 88–92% for patients at risk of hypercapnic respiratory failure such as severe COPD).

Circulation (C)

Assess cardiovascular stability and peripheral perfusion.

• Assessment: Evaluate capillary refill time (CRT) by pressing the sternum or distal phalanx for 5 seconds; normal CRT is $<2$ seconds. Measure radial and central (carotid/femoral) pulse rates, volume, and rhythm (normal pulse: 60–100 beats per minute). Measure blood pressure, assess skin temperature, color, and moisture, and measure urine output via catheterization ($<0.5\text{ mL/kg/hour}$ indicates poor renal perfusion/oliguria).
• Interventions: Establish large-bore intravenous (IV) access (e.g., 16G or 18G cannula), take blood samples (full blood count, broad biochemistry, blood cultures, lactate), and administer IV fluid boluses (e.g., 500 mL crystalloid over $<15$ minutes) as per local protocol and fluid balance guidelines.

Disability (D)

Assess central nervous system function and neurological status.

• Assessment: Evaluate consciousness level using the ACVPU scale (Alert, Confusion, Voice, Pain, Unresponsive) or the Glasgow Coma Scale (GCS). Check pupillary size, equality, and light reactivity. Measure blood glucose immediately to rule out hypoglycemia (normal fasting range: 4.0–7.0 mmol/L; hypoglycemia $<4.0\text{ mmol/L}$).
• Interventions: Reverse hypoglycemia with rapid-acting oral carbohydrates or IV 10% glucose; position unconscious patients laterally if safe; escalate low GCS ($\le 8$) for critical care/airway protection.

Exposure (E)

Conduct a full head-to-toe examination while preserving dignity and preventing hypothermia.

• Assessment: Inspect skin for rashes, surgical wounds, pressure ulcers, petechiae, or active bleeding. Recheck core body temperature (normal: 36.5–37.5°C).
• Interventions: Cover the patient with warming blankets, respect privacy, and document all physical findings accurately.

Primary vs. Secondary Assessment

• Primary Assessment: Rapid, sequential evaluation focused strictly on identifying and resolving immediate threats to life using the ABCDE algorithm.
• Secondary Assessment: A detailed, methodical head-to-toe examination and comprehensive history taken after the patient is stabilized and primary life threats are managed. Secondary assessment encompasses systematic physical examination of body systems (cardiovascular, respiratory, neurological, gastrointestinal, musculoskeletal) and comprehensive history taking.

Objective vs. Subjective Clinical Data

NMC registered nurses must distinguish between two primary forms of clinical evidence during health assessment:

• Objective Data: Measurable, observable physical facts obtained through direct examination, diagnostic testing, and vital sign measurement. Examples include blood pressure (124/78 mmHg), heart rate (82 bpm), serum potassium (4.2 mmol/L), and wound dimensions (3 cm x 2 cm).
• Subjective Data: Information reported directly by the patient or carer describing their personal feelings, perceptions, symptoms, and health history. Examples include statements like "I feel nauseous," "My pain feels like a burning sensation," or "I felt dizzy when I stood up."

Baseline Clinical Observations

Baseline vital sign observations establish the individual's normal physiological standard against which subsequent changes are evaluated. Complete baseline observations must include:

1. Respiratory rate (counted for 1 full minute).
2. Oxygen saturations ($SpO_2$) and specified inspired oxygen delivery (air vs. $O_2$ L/min).
3. Systolic and diastolic blood pressure (measured with appropriate cuff size).
4. Heart rate and pulse rhythm (radial/apical).
5. Level of consciousness (ACVPU / GCS).
6. Tympanic or oral body temperature.

Structured History Taking: SAMPLE & SOCRATES

SAMPLE Mnemonic

The SAMPLE framework provides a structured memory aid for collecting essential clinical history in acute and non-acute presentations:

• S – Signs & Symptoms: Chief complaint and visible/measurable clinical indicators.
• A – Allergies: Known drug allergies, food, latex, and specific allergic reaction details.
• M – Medications: Regular prescription items, over-the-counter drugs, herbal supplements, and adherence.
• P – Past Medical History: Relevant prior illnesses, surgeries, chronic conditions, and vaccinations.
• L – Last Oral Intake: Time and nature of last food or liquid ingested (crucial for surgical/anesthetic planning).
• E – Events Leading to Illness: Contextual trigger events or circumstances immediately preceding the acute episode.

SOCRATES Pain Assessment Framework

Pain is a subjective fifth vital sign requiring systematic, validated evaluation. The SOCRATES tool ensures comprehensive pain characterization:

• S – Site: Where is the pain located? Is it localized or diffuse?
• O – Onset: When did the pain start? Was it sudden or gradual? Is it continuous or intermittent?
• C – Character: Describe the quality of pain (e.g., sharp, aching, burning, throbbing, crushing, stabbing).
• R – Radiation: Does the pain move or radiate anywhere else (e.g., cardiac pain radiating to jaw or left arm)?
• A – Associated Symptoms: Are there accompanying symptoms like nausea, sweating, dyspnea, or numbness?
• T – Time course: Does the pain follow a pattern? Is it worse at specific times of day?
• E – Exacerbating / Relieving Factors: What makes the pain better or worse (e.g., movement, deep breath, analgesia, heat)?
• S – Severity: Score the pain intensity on a validated 0–10 numerical scale (or visual analogue scale).