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Clinical Practice Keywords ABCDE/Assessment/

Deterioration/Goals
Review
Assessment This article has been
double-blind peer reviewed

In this article...
● S
 tep-by-step description of the A-G method of patient assessment
● Benefits of using A-G assessment in emergency and routine situations
● How to use A-G assessment in daily nursing practice

Performing an A-G patient

assessment: a step-by-step guide
Key points
Author Xabi Cathala is lecturer, School of Health and Social Care/Institute of
The A-G assessment Vocational Learning; Calvin Moorley is associate professor for nursing research and
is a systematic diversity in care, School of Health and Social Care/Adult Nursing and Midwifery
approach useful Studies; both at London South Bank University.
in routine and
emergency Abstract The A-G method is a systematic and structured approach of assessing
situations patients, useful both in routine and emergency situations. It is based on the ABCDE
approach used when resuscitation may be needed, extended by two additional steps.
A-G stands for The ability to perform an A-G assessment is a key nursing skill, as it should be
airway, breathing, standard practice not only in critically ill or deteriorating patients, but in all patients
circulation, disability, receiving care.
exposure, further
information and Citation Cathala X, Moorley C (2020) Performing an A-G patient assessment: a
goals practical step-by-step guide. Nursing Times [online]; 116: 1, 53-55.

N
This offers a
systematic approach umerous assessments exist in
to patient nursing. They are vital tools in
assessments day-to-day practice. The A-G
assessment is becoming a com-
The ability to monly used tool in primary and secondary
perform an A-G care settings. It integrates the procedure
assessment is a mandated for resuscitation and emergency
key nursing skill situations. However, it is also useful for
systematic baseline patient assessment
Re-assessing and can improve patient mortality in hos-
regularly will help pital (Griffiths et al, 2018).
nurses detect A-G covers: airway, breathing, circula-
deterioration early tion, disability, exposure, further informa-
tion (including family and friends) and
goals (Benson, 2017). Its systematic
approach has been proven effective in iden-
tifying deteriorating patients or those at risk
of deterioration (Dean and Bowden, 2017).
Nurses performing the assessment
need to explain to the patient what they are
going to do and seek their informed con-
sent. Before approaching the patient, they
need to undertake a risk assessment of the
environment to determine whether it is
safe to undertake the A-G assessment.
This article is based on the Resuscitation
Council’s approach to an A-E assessment
(Resuscitation Council UK, 2015) and guid-
ance from Benson (2017) on how to undertake
the F and G elements. Using this structured
approach can ensure the reliability of the
assessment in any situation. An A-G assess-
ment is not only used in critically ill or dete-
riorating patients, but should be standard
practice for all patients receiving care. It nor-
mally takes a few minutes to complete
depending on the practitioner’s experience.
Airway
The airway includes the nose, mouth,
larynx, pharynx, trachea, bronchi and
bronchioles (Cathala and Costa, 2019). Its
main function is to carry air into the body.
The aim of airway assessment is to ensure
this anatomical function is achieved and
any obstruction (full or partial) of the
airway is identified (Table 1). An indication
of a patent airway is the patient’s ability to
speak with a usual voice in full sentences.
Breathing
Breathing is the process by which air
moves in and out of the lungs, allowing
gaseous exchange. It should be:

Nursing Times [online] January 2020 / Vol 116 Issue 1 53 www.nursingtimes.net


Clinical Practice
Review
Table 1. Main causes and signs
of airway obstruction
Main causes of airway obstruction
● In healthcare settings, compromised
airway is often a result of altered level
of consciousness
●F  oreign body, aspiration
● Laryngotracheal trauma
● Vocal cord paralysis
● Allergic reaction
● Laryngeal oedema
● Oedema
● Haematoma
● Abscess
Signs of partial airway obstruction
● Breathing sounds (gurgling, stridor,
bubbling, expiratory wheeze)
● Choking
● Gasping for air
● Laboured breathing (possibly noisy)
● Coughing
● Reduced level of consciousness
● Unable to speak in full sentences
● Use of accessory muscles in breathing
Signs of complete airway obstruction
● Agitation
● Patient unable to speak
● Difficulty breathing
● No air entry at the auscultation
(no chest movement, or ‘see-saw’
breathing)
● Gasping for air
● Choking
● Panic
● Cyanosis (late sign)
● High-pitched breathing noises
(wheezing)
● Unconsciousness
● Stridor
l E
 ffortless;
l E
 qual bilateral chest expansion;
l A t a rate of 12-20 breaths per minute
(respiratory rate);
l N oise-free; that is, no wheezing, stridor
(a harsh vibrating noise) or rattling;
l The airway should be free of sputum.
During the assessment, nurses must
use the Look, Listen and Feel technique.
Looking for any respiratory distress signs
(Box 1), assessing the depth and pattern of
the respiratory cycle for 15 seconds and
counting the respiratory rate for a full
minute is recommended The acceptable
oxygen saturation is >96% for patients
without hypercapnic respiratory failure or
chronic obstructive pulmonary disease
(COPD) and 88-92% for patients with those
conditions or at risk of worsening
Nursing Times [online] January 2020 / Vol 116 Issue 1
hypercapnia (Williams, 2019; National
Guideline Centre, 2010; National Institute
for Health and Care Excellence, 2018;
O’Driscoll et al, 2008). The patient’s ability
to talk in full sentences is a good indicator
of their breathing status.
Listening to the breathing sounds can
give an idea of the cause of any breathing
difficulty. Rattling noises can indicate
secretion, wheezing can infer asthma,
while stridor can suggest partial airway
obstruction (Cathala and Costa, 2019).
Placing both hands on the patient’s chest
to feel for the rise and fall that accompany
breathing will help nurses assess chest
expansion and determine symmetry between
the right and left lungs. Consent need to be
obtained from the patient and a chaperone
should be offered where indicated.
A more accurate assessment is an aus-
cultation with stethoscope, but this
requires advanced skills.
Circulation
Assessing circulation is not limited to an
assessment of the heart. It is focused on
the haemodynamic and vascular parts of
the circulatory system.
This assessment starts with the periph-
eries. Are the hands and fingers blue, pink,
pale, warm, cold? Blue, pale and cold can
reflect a poor peripheral circulation, while
pink and warm are linked with a good
peripheral circulation.
Another useful measure is capillary
refill time (CRT). A CRT <2 seconds sug-
gests a good peripheral perfusion (Sansone
et al, 2017).
The next part of the assessment is the
heart rate, taking the peripheral or central
pulse. Assessing the pulse involves deter-
mining its presence, regularity, quality and
volume for 15 seconds. The rate is assessed
for one full minute. An acceptable heart rate
should be between 51 and 90 beats per minute
(Royal College of Physicians, 2017). The pulse
should be regular and strong or bounding.
An acceptable systolic blood pressure is
between 111 and 219 mmHg (Royal College of
Physicians, 2017). Clinical readings should
be interpreted with caution. If the systolic
blood pressure differs by ≥10mmHg from
the patient’s baseline, the result should be
reviewed with another member of the team.
Although diastolic blood pressure is not
part of the NEWS 2 scoring system a reading
it will give a good indication of the patient’s
haemodynamic status. The estimation of
the patient’s fluid input and output should
be calculated using the formula.
It is important to identify signs of haem-
orrhage, check whether there is a drain
54
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present, monitor its output regularly, and
ensure the patient has patent intravenous
access, so that fluids can be administered
in case of an emergency (Cathala and
Moorley, 2018) (see Box 2).
Disability
Disability assessment focuses on the main
causes of reduced consciousness such as
fainting (falls and mobility), drugs (polyp-
harmacy and side effects), alcohol, poisons
and hypoglycaemia. The patient’s ACVPU
status should be assessed. ACPVU stands
for alert, confusion (new), response to
voice, painful stimuli, and unconscious
(Smith et al, 2017).
Other areas of the assessment include
the pupillary size and reaction to light:
pupils should be of equal size and shape
and reactive to light. Nurses also need to
check the medication chart looking for any
drug-induced effects.
Measuring blood glucose is an important
part of disability assessment. Hypoglycaemia
(blood glucose <4.0mmol/L) can reduce the
patient’s consciousness level (Kitsuta, 2006)
and needs to be treated following local trust
policies and guidelines. Clinical judgement
should be used if the patient is not diabetic;
blood glucose levels may not need to be
checked but if there are signs of altered levels
of consciousness (Box 3) then the blood glu-
cose level should be measured. Measuring
arterial or venous blood gas can be helpful in
such situations. In diabetic patients with
high blood sugar levels, it is important to
look for signs of ketoacidosis (Box 3).
Box 1. Respiratory warning
signs
l Respiratory distress signs: sweating,
central cyanosis, use of accessory
respiratory muscles (abdominal
breathing, ‘see-saw’ breathing)
l Respiratory rate <12bpm or >20bpm
l Oxygen saturations outside the
normal values, which are:
l >96% for patients without
hypercapnic respiratory failure or
with chronic obstructive
pulmonary disease (COPD)
l 88-92% for patients with
hypercapnic respiratory failure
or with chronic obstructive
pulmonary disease (COPD) or at
risk of worsening hypercapnia
l Breathing noises: rattling, wheezing,
stridor, coughing
l Unequal air entry: asymmetrical rise
and fall of the chest
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Clinical Practice
Review
Pain should be assessed using a tool such
as PQRST (palliate/provoke, quality,
radiate, severity/scoring, timing (Falk and
Hudson, 2016). A bowel assessment should
be undertaken, determining last bowel
movement and the quality of the stool
using a tool such as the Bristol stool chart. A
medication history, including recreational
drugs and alcohol consumption should be
taken. Asking for any change in mobility
and any falls in the past six months com-
pletes the disability assessment.
Exposure
In exposure, nurses will assess the patient
for skin rashes, wounds, pressure injury,
signs of infection, bruises, skin changes
(turgor). A tool such as aSSKINg (assess-
ment, skin assessment and skin care, sur-
face, skin, keep, incontinent, nutrition)
can be used (NHS Improvement, 2018).
Venous thromboembolism (VTE) assess-
ment should be carried out, using ques-
tions such as:
l I s the patient at high or low risk of VTE?
l I s the patient wearing anti-embolism
stockings and/or compression devices?
l H as the patient been prescribed
anti-thrombolytic prophylaxis
treatment?
Nurses must ensure that the patient’s
dignity and privacy is maintained at all
times (including body exposure). In this
part of the assessment they will examine
the patient for signs of pressure injury.
Anti-embolism stockings should be
removed, as pressure injury can be hidden
underneath (NHS Improvement, 2018).
Nurses also need to check cannula and
drain sites for signs of infection, as well as
the patient’s temperature, which should
be between 36.1°C and 38.0°C (Royal Col-
lege of Physicians, 2017).
A nutritional screening should be
undertaken and recorded with a tool
such as the Malnutrition Universal
Screening Tool. To complete this exposure
assessment, confirm any allergies (drugs,
medication, food, chemicals) with the
patient against documentation and think
about which test(s) and investigation may
be relevant.
Further information
F stands for further information and
family and friends. Here nurses need to
gather additional information from
sources such as drug charts, medical
notes, investigation results and friends
and relatives. A social assessment is
needed: who is the patient’s next of kin or
close relatives? Does the patient live alone;
Nursing Times [online] January 2020 / Vol 116 Issue 1
Box 2. Cardiovascular
warning signs
l Cold, blue peripheries
l Capillary refill time >2 seconds
l Heart rate <51bpm or >90bpm
l Irregular and/or weak pulse
l Systolic blood pressure <111mmHg
or >219mmHg
l Change in patient consciousness
l Urine output <0.5ml/kg/h
l Signs of haemorrhage
Box 3. Warning signs of
ketoacidosis
l Polyuria (excessive or abnormally
large urine output)
l Polydipsia (abnormal thirst)
l Vomiting
l Abdominal pain
l Breath smelling fruity
l Deep or fast breathing
l Very tired or sleepy
l Confusion
l High levels of ketone in blood
(>0.6mmol/L) or urine (>2 +)
Box 4. Disability warning
signs
l Change in ACVPU status
l Significant increase in oxygen
requirements
l Change in pupils’ size and/or reaction
to light
l Drug-induced effect after dose
administration
l Blood sugar <4.0mmol/L
l Hypoxia or hypercapnia
l Change in bowel movement
l Presence and/or increasing levels
of pain
l Change in mobility or recent falls.
ACVPU = Alert, Confusion (new), response
to Voice, Painful stimuli, Unconscious
in a flat or a house? What is access to the
building like? This will allow nurses to
develop a picture of the patient’s environ-
ment, understand their needs and deter-
mine who needs to be involved in their
care. This is particularly important for
inpatients awaiting discharge.
Goals
Goals set for the patient will be based on
the results of the assessment. The fol-
lowing questions can be useful:
l W hat are the goals for the patient (both
short- and long-term)?
55
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W
 hat is the monitoring plan?
l
It is best practice to use a SMART (spe-
cific, measurable, achievable, realistic and
timely) approach. The practitioner should
objectively document patient notes and
NEWS charts; and escalate if necessary as
per local policies. For handovers, using a
structured approach such as SBAR (situa-
tion, background, assessment, recom-
mendations) is useful. It is important to
reassess patients if their status changes or
as per the monitoring plan put in place.
Conclusion
The ability to perform an A-G assessment
is an important if not mandatory skill. All
nurses should be confident and competent
in this global systematic practice. Carrying
out A-G assessments regularly helps
nurses to detect any changes and deterio-
ration and ensure it is safe to provide care
to the patient. It enables fast action,
improving quality of care, patient safety
and outcomes. The A-G method could be
considered a gold standard assessment. NT
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