![]()
1
Initial Assessment of the Acute Medical Patient
Judith Morgan and Ian Wood
Aims
This chapter will:
- describe a systematic approach for the initial assessment and management of acute medical patients
- discuss the components of physical assessment, history-taking and prioritisation
- discuss the principles of documentation and discharge planning as part of the initial assessment process
Introduction
Accurate assessment and the ability to prioritise and manage patients’ needs underpin safe and effective practice in acute care settings. If initial assessment is inadequate, the clinical risk for the patient increases. Assessment involves the gathering of information regarding the patient’s current physiological and psychological status along with a history of the present and past medical events. On seeing the patient for the first time, the assessment process begins. An initial ‘eyeball’ of the patient will quickly identify whether they are alert and talking, their age, sex, general appearance, behaviour and demeanour. Alongside this process, relevant investigations to aid diagnosis should be initiated, and appropriate treatments and care commenced. Early and effective assessment and initiation of investigations are essential if prompt and accurate decisions regarding the patient’s need for medical attention, hospital admission or transfer to a more appropriate care setting are to be made.
The assessment process should always be carried out systematically, and comprises the following components:
- systematic physical assessment (Airway, Breathing, Circulation, Disability, Exposure)
- history taking
- prioritisation of needs
- documentation of findings
- discharge planning
Systematic physical assessment (ABCDE)
Using the systematic ABCDE approach helps in the identification of serious, life-threatening complaints or complications at the earliest opportunity and saves lives. The identification and management of airway problems before the assessment of breathing is crucial, as an unrecognised airway problem may be the cause of a patient’s breathing difficulties. As the first physiological responses to illness normally occur in the respiratory system, and breathing has a direct impact on the circulatory system (i.e. the circulation is dependent on oxygen supply), it is crucial to identify and correct life-threatening breathing problems before making an assessment of circulatory function. Once the patient’s circulatory status has been assessed and problems managed, an assessment of neurological disability can be made. This systematic approach to the initial assessment of all patients is completed by undressing the patient (exposure), thus ensuring that important clinical indicators are not missed. As a baseline for this assessment, Table 1.1 gives details of normal adult physiological values.
Airway
Assess the patency of the patient’s airway. In most cases, this will be a formality as the patient will be alert and talking. However, those patients who are unconscious or semi-conscious may not be able to maintain a clear airway, particularly if they are positioned supine. Failure to clear the airway will lead to inadequate ventilation of the lungs and reduced oxygenation. Complete airway occlusion will quickly result in respiratory arrest which, without intervention, will proceed to a full cardiac arrest. The other patients who are at risk of airway compromise are those presenting with an allergic response where the lips and tongue can swell and, if not treated promptly, can lead to full airway obstruction.
Look at the patient’s chest for signs of accessory muscle use that may indicate increased respiratory effort caused by airway obstruction. Look at their lips and oral mucosa for cyanosis, pallor (with dark skins this may be difficult to assess), swelling, dryness or cracking. Check whether the patient has false teeth and if they are well fitting. If false teeth are ill fitting, remove them as they can cause obstruction. Listen for noise in the airway. Inspiratory noise (stridor) can be indicative of upper airway obstruction. Expiratory noise (wheeze) can indicate lower respiratory problems caused by airway collapse on expiration, e.g. acute asthma. A swollen, dry or cracked tongue can be indicative of dehydration.
Table 1.1 Baseline physiological values for adults
| Respiratory rate | 12–20 per minute |
| Heart rate | |
| Normal | 60–100 beats per minute |
| Bradycardia | < 60 beats per minute |
| Tachycardia | > 100 beats per minute |
| Blood pressure | |
| Systolic | > 90 mmHg |
| Oxygen saturation | |
| Normal | 95–98% |
In the unconscious patient, look inside the mouth for saliva, frothy sputum which can be pink in colour (pulmonary oedema), blood-stained spit (pulmonary embolism, TB, lung trauma), blood, vomit or foreign bodies. If the patient vomits, use suction to help clear large amounts of material from the mouth and oropharynx and tilt the head of the bed down to reduce the likelihood of pulmonary aspiration. In airway management, nursing interventions include clearing of obstructions (e.g. foreign bodies, poorly fitting dentures, vomit and flaccid tongue), use of head-tilt/chin-lift manoeuvres, administration of suction, insertion of airway adjuncts (oropharyngeal or nasopharyngeal airways) and moving the patient into the recovery position. If using suction through airway adjuncts, suctioning for more than 15 seconds can deplete the lungs of oxygen, so great care should be taken. If, when checking the airway, there is an inability to open the mouth due to muscle spasm, then trismus is present and insertion of a nasopharyngeal airway may be required. Further assessment of the airway includes obtaining any history relating to possible causes of airway problems (e.g. does the patient have any allergies that may have caused an airway problem?).
Breathing
Inadequate breathing may be acute or chronic, continuous or intermittent, and can lead to inadequate ventilation of the lungs and subsequent respiratory failure. Initial assessment of breathing focuses on the identification of immediately or potentially life-threatening conditions (Box 1.1; see also Chapter 7 − Shortness of breath and Chapter 8 − Chest pain), an increase in respiration rate is the first sign of the patient’s condition deteriorating (Moore & Woodhouse 2004).
While considering the presence of one or more of these conditions, look at the patient for central or peripheral cyanosis. Assessing the pattern and rate of respiration is of vital significance (Kennedy 2007) as the respiration rate has been found to be a key predictor of cardiac arrest or a critically ill patient requiring intensive care (Goldhill et al. 1999). Count the respiratory rate using a stethoscope and assess the depth and effort of breathing. Measure the oxygen saturations using a pulse oximeter. Look at the symmetry of the patient’s chest movements. Assess the patient for use of accessory muscles and for retraction of the skin around the clavicles and ribs, indicating increased respiratory effort. Listen for sounds of stridor or wheeze on inspiration (upper respiratory infections), on expiration (bronchospasm) or biphasic (wheeze on inspiration and expiration – foreign body, laryngospasm or very severe asthma attack). Assess whether the patient can talk in complete, full sentences, short sentences, words only, or is unable...
