Airway

2.Look – Is there any visible obstruction in the patient’s mouth or upper airway? What is the
patient’s skin colour? Is there any evidence of pallor or cyanosis? Is there any ‘see-sawing’ of the
chest and abdomen, indicating complete airway obstruction?

3.Listen – Can the patient speak? Are there any added noises such as crowing (indicating a dry
obstruction) or gurgling and/or bubbling (indicating a wet obstruction)? Are there any sounds of
forced air entry in the upper airway (stridor)?

4.Feel – Can you feel the passage of air at the patient’s nostrils and mouth?

Breathing

5.Look – Observe the rate, rhythm and depth of the patient’s respirations over a period of one
minute. Is there any evidence of the use of the accessory muscles of respiration (indicating difficulty
in breathing)? Has the patient’s colour improved or worsened? What is the patient’s oxygen
saturation level? Measure the oxygen saturation level using a pulse oximeter. Can you see any
tracheal deviation?

6.Listen – Listen to the patient’s breathing using a stethoscope or auscultate the patient’s lower
airways and lungs if competent in these skills. Are there any additional noises such as crackles or
wheezing?

7.Feel – Palpate the patient’s chest. Is thoracic expansion symmetrical?

Circulation

8.Look – What is the patient’s capillary refill time, indicating their level of tissue perfusion? This
should be two seconds and is measured by compressing the nail bed or fingertip for five seconds
while it is elevated above the level of the heart, before observing how long it takes for the resultant
blanching to return to normal (Figure 1). Monitor urine output and measure temperature using a
thermometer. Check to see if the patient has intravenous access.

9.Listen – Perform a manual assessment of the patient’s blood pressure using a

sphygmomanometer.

10.Feel – Assess the patient’s pulse rate, as well as its rhythm and depth.
Disability

11.Assessment of the patient’s level of consciousness using the AVPU (Alert, responds to Voice,
responds to Pain, Unresponsive) scale (Resuscitation Council (UK) 2015).

12.Measure the patient’s blood glucose level using a blood glucose measuring device. Is it within
normal parameters? Record all clinical data and note any abnormal readings.

13.Observe the patient’s pupils. Are they both equal in size and reacting to the light stimulus from a
pen torch? (Figure 2).

14.Is the patient complaining of any pain? Use a scoring tool to objectively assess this.

15.Have you observed any seizures in the patient?

Exposure

16.While maintaining the patient’s privacy and dignity, perform a head to toe assessment (both
front and back) looking, listening and feeling for any physiological abnormalities which might
indicate the cause of the patient’s acute deterioration. For example, these might include any rashes,
abdominal swelling, or evidence of deep vein thrombosis. The practitioner should examine any
wound site and associated dressings or surgical drains for haemorrhage.