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Place the statements/comments in the correct order when undertaking an A-E Assessment on a patientThink about the “task” or “observation” that is being undertaken within the following statement/comment , and place it in the correct order(Some Trusts may want to undertake F and G, so there are statements relevant to these ) | Gold Standard | Goals | Set time parameters for review | Temperature | Pain Assessment | Level of Consciousness | Heart Rate | Respiratory Rate | Patient airway | Obstructed fully/partial | Depth-shallow, laboured | Pulse location-e.g. Radial etc. | Capillary Refill Time | Capillary Blood Glucose | Temperature site and method used | Psychological assessment | No airway risk | Asymmetrical chest movements | Quality of pulse volume | AVPU | Hypo/Hyperthermia | Social assessment | Adjuncts used | Wheeze | Blood Pressure | GCS | Rashes | Tracheostomy | Talking in full or short sentences, monsylabells | Skin Assessment | Pain Assessment | Wounds | Laryngectomy | Use of Accessory muscles | Cold, clammy, dry | Pressure Ulcer Risk Assessment | Last ate/drank | Cough- dry, productive | Urine Output | Analgesia – time given | Skin integrity and score | Peripheral/central cyanosis | Oxygen saturation | Peak Flow | Prescribed oxygen delivery | Chest drain insitu | | |

ABCDE | No airway risk, Patent airway, Larygectomy/trachy, Adjuncts used, Obstructed fully/partialRR, rhythm, rate, depth, stridor, assymetrical chest movement, accessory muscles, cough, talking/not, o2sat/delivery (route), chest drain institu (bubbling or swinging), cyanosisHR, qualityof pulse volume(Force of blood being pumped out of d left ventricle, hitting the aortic arch), BP, skin assessment, cold & clammy, urine output (BP must be maintained above 80 for the kidney to function effectively), CRT (cappilary refill time) AVPU (if patient is only responding

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