# data[].attributes.body
Michalea's A-E Assessment
Airway: Patent - Michaela is able to maintain her own airway. No added sounds.
Breathing: When you look, listen, and feel Michaela does not seem to be struggling to breathe when you count for 1 minute you find that her respiration is 22 bpm.
O2 Saturation - 96%
Circulation: Pulse rate 110 bpm regular and thready. B/P 130/85
Disability: Blood glucose 3 mmol, pupils are equal and reactive. Relatives of Michaela are concerned that her speech is not coherent and she does not recognise she is in hospital.
Exposure: Temp 36.2. No abnormality on exposure.

# data[].attributes.body
Find information of what good documentation should look like.

# data[].attributes.attachment_link.title
Blood Pressure: Korotkoff Sounds | Ausmed Explains...

# data[].attributes.body
What does the A-E assessment stand for?

# data[].attributes.attachment_caption
From the scenario list, how would you consider prioritising the care of these patients?

# data[].attributes.body
Situation: Frankie is a 45-year-old homeless woman who has been admitted with abdominal pain.
Background: Frankie has been homeless for the past 9 months since she and her partner separated and she lost her job.
Assessment: Frankie looks unkempt, she is in a lot of discomfort.
Recommendation: You are working in the A&E department with your practice supervisor who has asked you to take Frankie's vital signs and assist Frankie with a bed bath.
Decision: Document and hand over to your practice supervisor the care you have given Frankie.

# data[].attributes.body
List ways of making communication effective.

# data[].attributes.body
Good documentation should include:

confirmation of identity

concise writing

documenting as frequently as needed e.g. hourly, twice a day / when a major event happens

done immediately (or as soon as you can) - as close to the time the care was given

writing exactly what you see

factual, not opinion - accurate and relevant to the individual

relevant to the assessment carried out

no jargon

accurate time and dates

when, where and why

care plans, risk assessments, medication administration

physical notes - e.g. weight, height, etc.

avoid duplication of notes / do not copy and paste

ensure you have the right details

proofreading of written notes

# data[].attributes.body
Gemma's A-E Assessment
Airway: Gemma is talking to her mother unable to complete full sentences.
Breathing: When you look, listen, and feel Gemma's respiratory rate seems fast, you can hear a wheeze and when you expose her chest of Gemma you see accessory muscles working hard. Respiratory rate 35.
O2 Saturation - 89%
Circulation: Pulse rate 120 bpm regular and strong. B/P 110/65
Disability: Gemma remains alert, pupils are equal and reactive to light. Blood sugar - 6 mmols
Exposure: On exposure, we notice accessory muscles are working very hard. Temp 36.2

# data[].attributes.headline
Understanding the audio-visual skill of blood pressure reading

# data[].attributes.subject
Understanding the audio-visual skill of blood pressure reading

# data[].attributes.attachment_link.title
LearningTools: Blood Pressure Basics - Audio-Visual Coordination Skills

# data[].attributes.body
What does a physical assessment entail? What would you consider with regards to Frankie?

# data[].attributes.body
What is prioritisation of care?
Why is prioritisation of care important?
What skills are needed to prioritise care?
Can you name any assessment tools used to aid prioritisation?

# data[].attributes.body
What is the main role of communication?
What are the four main methods of communication?

# data[].attributes.headline
Video: how to undertake a manual blood pressure

# data[].attributes.subject
Video: how to undertake a manual blood pressure

# data[].attributes.attachment_link.readable_text
Improve Article 👀

Blood pressure (BP) measurement often appears in OSCEs and you'll be expected to confidently carry out the procedure. This blood pressure measurement OSCE guide provides a clear step-by-step approach to measuring blood pressure, with an included video demonstration.

Gather equipment

Gather the relevant equipment for measuring blood pressure:

Stethoscope

Sphygmomanometer: ensure you have an appropriately sized cuff. A cuff that's too small may overestimate BP, and a cuff that is too large will underestimate BP.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "Today I would like to measure your blood pressure, this will involve inflating a cuff around your arm whilst listening to your pulse with my stethoscope. The procedure shouldn't be painful, but it may feel a little uncomfortable when the cuff is fully inflated and you might experience some pins and needles in your hand. If at any point you want me to stop, just let me know."

Gain consent to proceed with blood pressure measurement.

Position the patient sitting on a chair, with their arm comfortably placed at approximately heart level.

Check if the patient has a preference as to which arm to use. Avoid using an arm that has local pathology such as post-mastectomy lymphoedema.

Ask the patient to adequately expose their upper arm on the relevant side by rolling up their sleeve.

Check if the patient has any pain before proceeding with blood pressure measurement.

You might also be interested in our collection of 900+ OSCE Stations, including a range of practical procedure stations.

Attaching the blood pressure cuff

1. Check that the blood pressure cuff size is appropriate for the patient's arm and that it is fully deflated.

2. Confirm the location of the brachial artery by palpating medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.

3. Wrap the blood pressure cuff around the patient's upper arm, lining up the cuff marker with the brachial artery.

Measuring blood pressure

Estimate an approximate systolic blood pressure

To begin with, you need to determine an approximate systolic blood pressure. This is helpful in preventing over-tightening of the cuff during the accurate measurement of blood pressure.

1. Ensure the valve on the blood pressure cuff is closed.

2. Palpate the patient's radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

3. Inflate the blood pressure cuff until you can no longer feel the patient's radial pulse. Note the reading on the sphygmomanometer at the point at which the radial pulse becomes impalpable. This reading is an approximate estimate of the patient's systolic blood pressure.

4. Open the valve and deflate the blood pressure cuff.

Measure the blood pressure accurately

Now that you have an approximate systolic pressure, you can perform an accurate assessment of systolic and diastolic blood pressure.

1. Close the valve on the blood pressure cuff.

2. Position the diaphragm of your stethoscope over the brachial artery.

3. Re-inflate the cuff 20-30 mmHg above the systolic blood pressure you previously estimated.

4. Then slowly deflate the cuff at around 2-3 mmHg per second.

5. Using your stethoscope, listen carefully for the onset of a pulsatile noise. The first of these pulsatile noises is known as the first Korotkoff sound. The pressure at which the first Korotkoff sound becomes audible represents the patient's systolic blood pressure.

6. Continue to deflate the cuff, whilst listening through your stethoscope until the pulsatile sound completely disappears. The final pulsatile noise you hear is known as the fifth Korotkoff sound and represents the patient's diastolic blood pressure.

7. If the patient's blood pressure is outside of the normal range you should repeat the assessment on the same arm after a few minutes and also consider assessing blood pressure using the patient's other arm.

Blood pressure abnormalities

Blood pressure abnormalities may include:

Hypertension: blood pressure of greater than or equal to 140/90 mmHg if under 80 years old or greater than or equal to 150/90 mmHg if you're over 80 years old.

Hypotension: blood pressure of less than 90/60 mmHg.

Narrow pulse pressure: less than 25 mmHg of difference between the systolic and diastolic blood pressure. Causes include aortic stenosis, congestive heart failure and cardiac tamponade.

Wide pulse pressure: more than 100 mmHg of difference between systolic and diastolic blood pressure. Causes include aortic regurgitation and aortic dissection.

Difference between arms: more than 20 mmHg difference in blood pressure between each arm is abnormal and may suggest aortic dissection.

To complete the procedure

Once a blood pressure recording has been obtained, remove the blood pressure cuff.

Explain to the patient that the procedure is now complete.

Discuss the blood pressure results with the patient, including any further steps that may need to occur (e.g. follow-up, further investigations, initiation of treatment).

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Document the lowest blood pressure recording in the patient's notes.

Reviewer

Michelle Spence
Senior Nurse Practitioner

# data[].attributes.attachment_link.title
Blood Pressure Measurement - OSCE Guide | BP Reading | Geeky Medics

# data[].attributes.attachment_link.description
A step-by-step guide to blood pressure (BP) measurement in an OSCE setting, with an included video demonstration.

# data[].attributes.body
What observations are part of vital signs?

List the normal ranges for each of the vital signs.

# data[].attributes.attachment_link.title
NMC OSCE NEWS CHARTS / NEWS 2 / National Early Warning Scoring System Explained / How to Chart OSCE

# data[].attributes.attachment_link.title
Vital Signs: Temperature, Pulse, Respirations & Blood Pressure - Clinical Skills | @LevelUpRN

# data[].attributes.attachment_caption
A to E Assessment - ABDCE Clinical Approach

# data[].attributes.attachment_link.title
A to E Assessment for Deteriorating and Acutely Unwell Patients | ABDCE Clinical Approach

# data[].attributes.body
Using your knowledge of the A-E assessment read the scenario and go through an A-E assessment.
Situation: You are a student nurse walking to work. You see a homeless woman that you are concerned about. You call the emergency services
Background: You see this woman on your regular walk to work and know that she is a homeless person. When you saw her last night on the walk from work to home, she passed the normal pleasantries.
Assessment: You don't know what is wrong but you are worried. She looks pale and mottled hands/fingers responsive to pain only. Breathing is shallow respiration 10.
Recommendation: Explain what you need to do.

# data[].attributes.body
Situation: You are a student nurse working within a GP setting. You and your practice supervisor are running a drop-in clinic. Katia is a new mother who comes in and explains that she thinks her baby does not love her.
Background: Katia had been trying to have a baby for 5 years and went through 3 rounds of IVF. She is 9 weeks postbirth. Her birth was long with a failed induction and ended with an emergency caesarean.
Assessment: Katia is low in mood, and gets agitated at times and although she holds her baby her body language displays detachment from her child. She looks tired. You believe that Katia is suffering from postnatal depression.
Recommendation: Explain what you need to do and specify the timeline.

# data[].attributes.body
Situation: You are a student nurse working on the ward. You and your practice supervisor are caring for 6 patients. Marcus is a 14-year-old who was admitted last night with a temperature of 38, dry cough, and runny nose.
Background: Marcus has been out of sorts according to his mother. She says for the past 2 days he has had a dry cough Marcus started with a runny nose two days ago. Although she has been self-medicating with paracetamol and simple linctus. Last night Marcus became lethargic.
Assessment: Marcus looks very unwell. He has a dry cough, and runny nose and his eyes look watery. He has a high temperature.
Recommendation: This is Marcus' third day of symptoms. Explain what you need to do.

# data[].attributes.body
A - Airways

B - Breathing

C - Circulation

D - Disability

E - Exposure

F - Fluids

G - Glucose

For patient assessment it is good to:

Rule out physical conditions - do physical health assessment, e.g. vitals, ABCDE

Find priority needs

Consider patient triggers

Handover well through SBAR

Look at the person holistically - consider everything, including social circumstances

Vital signs:

Oxygen levels

Pulse

Temperature

Respiration rate

Blood pressure

Blood sugar levels

Consciousness?

Urine output

Blood test

Recommendation for scenario 1:

Call the ambulance

Explain your concerns/the location/description of the woman

Someone from the hospital to inform social services/homeless team

Scenario 2:

The lady needs an assessment to figure out her mental health and social needs (e.g. where is she living, who is she living with) - mental state examination

Capacity assessment - do social services need to be contacted? Safeguarding?

Referral to perinatal team?

# data[].attributes.body
Lesson Aim
To gain knowledge and understanding of Patient assessment by discussing the principles and techniques for patient assessment.

Outcomes

1. Students will develop a working knowledge and
understanding of what constitutes effective
communication.

2. Understand the importance of patient assessment.

3. Students will know how to perform a patient assessment
in a systematic way.
4.  Document findings from the case scenario.

5.  Students will hand over the care they have delivered
using an SBAR tool.

6. Participate in peer discussions and self-reflection.

# data[].attributes.body
Communication is sending and recieving information, to establish and understanding.

The four main methods of communication are: written, non verbal, verbal and visual.

Verbal communication can be understood as; language both written and spoken. For example, talking face to face, public speaking, preaching, monologue.

Non verbal communication can be understood as; the exchange of information without the use of speech. examples are: body language, smiling, gestures and posture, eye contact, sign language.

Written communication can be understood as; exchange of information using words and numbers. Examples are: sending emails, writing letters, sending text messages, report writing.

Visual communication can be understood as; the use of visual elements to convey ideas; signs, drawing, graphic desgins, illustration, industrial desgins.

Effective communication requires individuals to be clear and concise in communicating. This includes exchanging information with clarity, empathy and understanding.

# data[].attributes.body
The main role of communication is to exchange information so that information is relayed and understood clearly.

The four main ways of communication are verbal, written, non-verbal and visual.

# data[].attributes.body
It is important to introduce yourself to the patient and explain who you are.

It is important to make the patient feel comfortable, accepted, to be responsive, and to show empathy. This includes being warm and approachable - as often patients can feel discriminated against or stigmatised.

It is important to be a good listener, to gather information from the patient. Also to be non-judgemental. It is also good to provide reassurance.

It is also important to have good body language.

It is important to give the patient time, and not to rush them.

It is also good to provide an interpreter when necessary.

It is good to have detailed documentation including everything that the patient is telling us.

It is vital to obtain consent.

When communicating with the patient you need to ask them open questions in order to get more information.

4 ways of communicating:

Verbal, written, non-verbal, visual

# data[].attributes.body
Prioritising of care is the process nurses make in deciding what actions to take in the care of each patient, on the basis of importance. For example, division of tasks, allocating tasks to staff appropriately based on care needs. The ability to look at a situation and determine what is most important, time sensitive. It is also important for nurses to uphold patient centered care, involving patients in decisions regarding their care. For example priortising patients by providing patient choice to decided the type of service preferred.

1. Prioritising of care is important to prevent patients deteroriating, and situation worsening.

2. the ability of nurses prioritising patient care is paramount because, it is larger dertermined success or failure in delivering quality health care.

3. nurses with better prioritising skills would be better equipped to make strategic decisions, show excellent judgement, display strong time management skills.

Skills needed to prioritise care are:

good listening skills, time management, team work.

Assessment tools needed to prioritise care are:

1. assessing patients basic needs to determine appropriate treatment plan. One method is assessing NEWS2 early warning signs; pulse, breathing rate, temperature, oxygen saturation.

2. general observation is also tool of assessment. for example monitoring blood sugar levels.

3. interview is also an assessment tool as this provides nurses with the opportunity to assess patient history, current situation to determine treatment plan.

4. Activity of daily living scale

assessment can be understood as evaluating and determining most critical health care needs, based on the patient condition, the severvity and urgency. Also helps to identify, engage the extent of specific conditions and provide fair approach in response.

# data[].attributes.body
Prioritisation of care is the idea of prioritising your daily task according to the needs and urgency of the patients.

Prioritisation of care is important because it reflects on our duty of care and prevents an ill outcome. Also systematically helps you analyse the needs of the patient and saves times.

The skills needed; good communication, proactiveness, analytical skills, time management, good team player, knowing how to risk assess and competence.

Assessments used to prioritise care; observation (NEW2), 1-1, risk assessments, care plan, SMART, Waterlow assessment and Triage assessment.

# data[].attributes.body
What is communication :

Effective communication is the process of exchanging ideas thoughts, opinions, knowledge and data so that the message is received and understood with clarity and purpose.

For ex.

to minimise misunderstanding, and to develop strong relationships with patients and staff.

Types of communication

verbal, non-verbal, written, visual.

# data[].attributes.body
When thinking about prioritisation, it is important to:

Taking into consideration people's interests and care needs, including aspirations and goals. This includes promoting recovery.

Listen attentively - to try and figure out the most important things to prioritise. Pay attention to what is being said both verbally and non-verbally.

Consider risk factors - have background information about the patient and what they are currently experiencing in terms of their mental health, to know what to prioritise. e.g. risk of self harm/suicidal ideation. Prioritise to attempt to reduce the risk.

Involve the patient in the decision making, and also their family/guardian. (With the consent of the patient)

Skills we need to prioritise care:

Good communication skills: listening, involving an approved translator?

Good writing skills and documentation

Ability to create a good care plan that includes the identified priorities e.g. cultural, religious, dietary needs

Have knowledge and a good understanding about diversity, and what is suitable. To always seek consent

Assessment tools used to aid prioritisation:

SBAR

Observation chart/NEWS

CMA

# data[].attributes.body
Prioritisation of care

What is prioritisation of care?

-This is putting the interest of the patient using or needing services first

Why is prioritisation of care important?

-If you miss caring for immediate priorities the patient's health may worsen and become more difficult to manage/

What skills are needed to prioritise care?

-Good communication skills, effective teamwork, empathy, critical thinking and time management.

Can you name any assessment tools used to aid prioritisation?

-Vital signs, Addenbrooke's cognitive examination (ACE), two-stage capacity test.

# data[].attributes.body
What does the A-E assessment include

Airway

Breathing

Circulation

Disability

Exposure

An approach to the immediate assessment and treatment of critically ill or injured patients.

Frankie Case study

Patient walked in with abdominal pain, appeared unkempt, presented unwell, has history of homelessness. Frankie was assessed and reviewed by NIC. Recommendation was given and option of care was provided by NIC.

Introductions and purpose of assessment made to Frankie, Consent to treatment obtained.

Frankie's vitals were conducted.

Frankie was offered hot tea and snacks.

Frankies abdominal pain was assessed, and a reccomendation for medication was suggested to the NIC.

Frankie's mental state (mse) was assessed and documented.

Frankie was offered to have a bath, however she refused, she was then re-assured taking a bath would help her to feel better, which she eventually agreed to with the support of female nurse.

Frankie agreed to have a full nursing assesment later when she rested for a few hours.

What vital signs are conducted and what are the normal ranges?

Respiration rate: 12-16 breaths per minute

Pulse rate: 60-100

Blood pressure: 120/ 80

Saturation Levels : 95-100%. (SpO2). Sats for COPD would be between 88-92.

Body temperature: 36.5- 37.5 degree celisus

Conciousness: Alert, confused

Case study 2:

Contact 999

Introduce yourself and ask for the patients name

Ask if patient has taken any substances

Check the environment for hazards

Check patient airway as respiratory rate is low

Check patients pulse (manually)

Keep patient warm

Place patient in recovery position

Keep patient calm

# data[].attributes.body
A-E assessment; Airway, breathing, circulation, disability and exposure. A priority based approach for the assessment of critically ill patients.

A physical assessments includes physically examining the patient and helps us to critically analyse the level of illness a patient is at. In Frankie's case, we would begin by conducting the ABCDE assessment before immediately contacting emergency services.

The observations of body temperature, pulse rate, respiration rate and blood pressure, are all considered vital signs. This is because it indicates whether there body is functioning well and whether there is anything of concern to monitor.

normal ranges

blood pressure-120/80

respiration rate-12-18 breath per minute

pulse rate-60-100 beats per minute

temperature - 36-37.2c

# data[].attributes.body
What does A-E assessment stand for?

-Airway, Breathing, Circulation, Disability and Exposure.

What does physical assessment entail?

-It entails doing

1. AVPU (awake, voice, pain and unresponsive)

2. Blood glucose level

3. NEWs score

What would you consider about Frankie?

First scenario

1. Put the patient in a recovery position

2. call for help, ambulance

3. Check airway

4. listen to breathing

Katia scenario

1. Mental state examination

What observations are part of vital signs?

1. blood pressure

2. sats

3. temperature

4. pulse

5. heart rate

6. Blood monitoring

# data[].attributes.body
Good documentation should be;

1. Clearly written and to the point.

2. Confirm we are writing notes to the correct patient (e.g. right D.O.B)

3. Avoid late entries

4. Write down information accurately and in real time

5. Date, time and signature

6. Well detailed and contain factual information.

7. Should have agreed actions, plans and recommendations.

8. Prioritise legibility (others should be able to clearly understand the information)

9. Use the right tools e.g. nursing documents can be used for legal proceedings, for that reason use only black ink and never erase any information.

10. Follow policy

11. document physician consultations e.g. patient care including names, times, responses and any resulting actions which is critical in a case needed in an emergency.

12. No duplications

# data[].attributes.body
Should be clear and concise, recorded in a timely manner, factual, documented with no jargon, correct details input, should be easily read, dated and signed, if it’s physically written, should be in black ink, make sure to proof read before documenting,

# data[].attributes.body
What is good documentation? Documentation should aim to be comprehensive.

Be clear, concise and complete and it entails personal data.

personal data: patient names, DOB, address, Sex, Next of kin, email address, contact number. patient history, patient allergies, time and date clearly,

The record should include: assessment, planning and evaluation of care

# data[].attributes.body
Frankie is a 45 year old female admitted into A&E due to abdomen pain. Frankie complains of discomfort. Frankie appears to look poorly kept.

Vital signs obtained; NEWS2 0. Skin check done, all pressure areas intact. Assisted with personal hygiene; bed bath given.

Refer to Doctor for Analgesia and scan for abdomen.

Follow up for review.

# data[].attributes.body
Michaela has low blood sugar, so you would administer a sweet snack/glycogen and check blood glucose level after 15 minutes again. If vital signs do not change then escalate to doctor/ Diabetic nurse.

Carry out observations to ensure she has her fluids. Make sure the pt is sitting upright to aid with heart rate.

Gemma is screened to check if she COPD or Asthma. Once that is established Oxygen/Nebuliser is administered as prescribed by the Doctor. Also will ensure Gemma is sat upright and closely monitored. Will carry out an ECG and request a chest x-ray. Gemma will be kept on a cardiac monitor. Blood test should be done and VBG (Venus Blood Gas).

# data[].attributes.body
Black British Jamaican lady, 40 Years old,

Diagnosis ; Bipolar disorder (5 episodes, 1st episode at 22 years old)

Trigger ; Smoking cannabis which induced psychosis, rapid thoughts

Symptoms ; Loss of appetite, insomnia, hallucinations and delusions, confusion,

Intervention; Sectioned, received medication, receives family support, supportive nurses

# data[].attributes.body
SCENARIO FRANKIE

Clinical assessment

-Get the equipment ready

-First introduce yourself

-confirm patient details

-tell the patient what you will be doing and gain consent

- do the vital signs

- Inform the patient i am here to support with their personal care.

decision

Handover

-Frankie is a 45-year-old woman, who is reported HOMELESS with ABDOMINAL PAIN. she is been HOMELESS for the past 9Months due to her being SEPARATED from her partner, lost her JOB. She appears UNKEMPT and in PAIN. VITAL SIGNS has been done, scored (5) which means hourly check and documented. she was offered tea and a sandwich which she enjoyed

Recommendation

FRANKIE refuses personal care, VITAL SIGNS should be done hourly due to the news score of 5. The doctor has been informed about the patient.

# data[].attributes.body
Based on the information provided, Micheala has a News score of 5. Nurse in charge needs to escalate to senior doctor. She also needs half hourly observations minimum.

Gemma has a News score of 8 so nurse in charge needs to escalate to senior doctor. Gemma should be observed half hourly minimum.

# data[].attributes.body
Video:

Triggers:

Cannabis

Breakdown of relationship

Symptoms

Sleepless nights

Loss of appetite

Pressured speech

# data[].attributes.body
Michalea A-E Assessment

Respiration is 22bpm - 2

02 Saturation 96% -2

pulse rate 110bpm -1

B/P 130/85 -0

blood Glucose 3mmol

Temperature 36.2 - 0

Oxygen - AIR - 0

Cons - ALERT -0

NEWS TOTAL = 5

GEMMA A-E Assessment

Respiration is 35bpm - 3

02 Saturation 89% -3

pulse rate 120bpm -2

B/P 110/65 -1

blood Glucose 3mmol

Temperature 36.2 - 0

Oxygen - AIR - 0

Cons - ALERT -0

NEWS TOTAL = 9