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A:
- Elicit a response from patient (speak to them, tap them)
- Look for signs of hypoxia
- Put hand on chest to check breathing rate
- Listen to airway sounds
B:
- Put hand on chest to check breathing rate and symmetry
- Listening when they speak for abnormal breathing sounds
- Check O2 saturations
C:
- Check pulse
- Check capillary refill
- Check blood pressure
D:
- Elicit response from patient (alert, sedated)
- Check BGLs
- Perform a GCS
E:
- Check for physical trauma

# data[].attributes.body
A: Head to toe assessment
- provides a baseline understanding of the patient
- start with an overall inspection of the patient
- move to head, ears, eyes, nose & throat
- work way down the body systematically
- use inspection, palpation, percussion & auscultation
B: Wound Assessment

1. Identify the location of the wound.

2. Determine the cause of the wound.

3. Determine the stage of the wound.

4. Evaluate and measure the depth, length, and width of the wound.

C: Facial expressions
- evaluate the type of emotion that the patient is expressing:
- e.g crying or scrunched facial expressions may indicate pain or sadness
D: Deformities
- observe the head shape, size and mobility
- if the patient is able to stand, inspect for any postural deformities
E: Cuts & scratches
- check for depth or severity or cuts and scratches
-

# data[].attributes.body
A:
B:
C:
D:
E:

# data[].attributes.body
A: Enter the room and check for signs of hypoxia while closing the curtains for privacy. If patient responds when you ask a question then the airways are patent and move onto Breathing. If they don’t respond, place patient in recovery position and use suction to clear the airway. Repeat question.
B: When asking patient question place hand on chest and assess for rate of breathing and any abnormal sounds. Noisey breathing can indicate obstruction, may need to provide oxygen therapy for shortness of breath/check oxygen levels. Encourage deep breathing and coughing while sitting
C: palpating the pulse, assessing for regular or irregular heart rate as well as strength of the pulse (thready, weak, strong, normal).
D: Ask if patient has any pain in the body, adequate response. If they say they do have pain, we would have done a full pain assessment using validating pain assessment tool. Complete ECG.
E: check for any scars or cuts. Complete head to toe assessment, determine from facial expressions and injuries present. Question what they have been exposed to if they’re conscious.

# data[].attributes.body
A: Look for nasal prongs or Hudson mask when entering the room, talking to them to see if you get a verbal response, c-spine control, look in their airway.
B: Place hand on pt's chest and feel for the rate and depth. May also listen for any abnormal breathing sounds.
C: palpating their pulse. Assess for regular/ irregular HR as well as the strength (thready, weak, strong, normal, or bounding), assess for haemorrhage, colour of skin/ temp.
D: assess pain levels. if any pain reported, assess using a valid pain assessment tool. Head injury, alcohol/ drugs, GCS and neurological observations, assess pupils.
E: head to toe assessment, wound assessment, facial grimacing, any potential injuries.

# data[].attributes.body
A: asking question and check if the response has any abnormalities
B: rise and fall of the chest, check if the patient has O2 therapy administered, palpate the chest,
C: palpate for the pulse (whether heart rate is regular), feel for the temperature, capillary refill, colour
D: GCS, pupil size, BGLs
E: head-to-toe assessment, check for symmetry

# data[].attributes.body
Place hand on chest and assess for rate and depth of breathing and listening to any abnormal breathing sounds. Noisey breathing can indicate obstruction. Watching the chest rise and fall. Abnormal breathing pattern can indicate obstruction. Look to see if they have any oxygen therapy and if so how many litres and how is it applied eg hudson mask, nasal prongs.

# data[].attributes.body
-Pulse rate (irregular or regular) (strength: thready, weak, strong, normal or bounding)
-Colour of skin + temperature
-Capillary refill return
-BP
-Haemorrhage

# data[].attributes.body
- Look for signs of airway obstruction
- Elicit a response from patient
- Listen for signs of upper airway noises and sounds
- If airway soiled, need to be managed on side- to allow drainage from the mouth and nose
- Listen to the vocalisation of the exhale (using stethoscope)
- To assess risk of respiratory deterioration- assess patient ability to protect their airway (through coughing and gag reflex)
- Placing the hand on chest to assess the rate and depth of breathing
- Look for signs of hypoxia (change in colour)

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head injury
alcohol
drugs
medication
blood loss
low levels of O2 saturation
sleep deprivation

- look at the patient's GCS to check consciousness
- pupil size
- vital signs
- look for injuries
- blood sugar levels

# data[].attributes.body
- Head to toe assessment
- Wound assessment
- Facial expressions
- Deformities
- Cuts/scratches