Abcde Approach Case Study

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In the first step of the Tanner (2006) model nurses use their personal knowledge and experience to notice whether the patient requires attentions based on their expectations and looking at environment of the patient. Therefore, for an experience nurse it is easier for them responding to the similar situation if she or he revisit because the knowledge is already there through experience. In the case of Mr Devi, assessment will perform using systematic assessment based on the ABCDE approach (Airway, Breathing, circulation, Disability and Exposure). The ABCDE approach is an evidence-based practice widely accepted and used by all the members of a multidisciplinary team (MDT) to assess an acutely ill patient (Harrison and Daly 2011). First, life-threatening…show more content…
Pulse oximeter used to check his oxygen saturation level, which was 98% on air with no central or peripheral cyanosis. Since Mr Devi, does not seem to have any sign of abnormal respiration. The next assessment is circulation, where there are many physical signs to look for. The colour of the hand and digits, are they blue, pink, pale or mottled. Also need to measure for capillary refill time (CRT) by applying cutaneous pressure for 5 Sec on a fingertip held at heart level of Mr. Devi. The normal value of CRT is usually less than 2 second prolonged CRT suggests poor peripheral perfusion. Measure his Blood Pressure (B/P), count pulse rate by listening to the heart with a stethoscope or palpate peripheral and central pulses, assessing for the presence, rate, quality, regularity and equality. All of this assessment indicates the cardiovascular system in the patient is within the normal range or is there any emergency measures should take ( 2016). However, Mr Devi’s circulation is a concern because his HR was 110bpm which is higher than normal range, the normal heart beat for adults ranges from 60-100bpm. Also his BP was 190/99mmhg with mean arterial pressure (MAP) of
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