The A-G method is a systematic and structured approach to patient assessment useful both in daily nursing practice and emergency situations. This article provides a step-by-step description of the method
The A-G method is a systematic and structured approach of assessing 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. The ability to perform an A-G assessment is a key nursing skill, as it should be standard practice not only in critically ill or deteriorating patients, but in all patients receiving care. Citation: Cathala X, Moorley C (2020) Performing an A-G patient assessment: a practical step-by-step guide. Nursing Times [online]; 116: 1, 53-55. Author: Xabi Cathala is lecturer, School of Health and Social Care/Institute of Vocational Learning; Calvin Moorley is associate professor for nursing research and diversity in care, School of Health and Social Care/Adult Nursing and Midwifery Studies; both at London South Bank University.
Numerous assessments exist in nursing. They are vital tools in day-to-day practice. The A-G assessment is becoming a commonly used tool in primary and secondary care settings. It integrates the procedure mandated for resuscitation and emergency situations. However, it is also useful for systematic baseline patient assessment and can improve patient mortality in hospital (Griffiths et al, 2018). A-G covers: airway, breathing, circulation, disability, exposure, further information (including family and friends) and goals (Benson, 2017). Its systematic approach has been proven effective in identifying 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 consent. 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 guidance 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 assessment is not only used in critically ill or deteriorating patients, but should be standard practice for all patients receiving care. It normally takes a few minutes to complete depending on the practitioner’s experience. AirwayThe 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.  BreathingBreathing is the process by which air moves in and out of the lungs, allowing gaseous exchange. It should be:
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 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.
Box 1. Respiratory warning signs
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 auscultation with stethoscope, but this requires advanced skills. CirculationAssessing 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 peripheries. 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 suggests 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 determining 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 haemorrhage, check whether there is a drain 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).
Box 2. Cardiovascular warning signs
DisabilityDisability assessment focuses on the main causes of reduced consciousness such as fainting (falls and mobility), drugs (polypharmacy 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 glucose 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 3. Warning signs of ketoacidosis
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 completes the disability assessment. ExposureIn exposure, nurses will assess the patient for skin rashes, wounds, pressure injury, signs of infection, bruises, skin changes (turgor). A tool such as aSSKINg (assessment, skin assessment and skin care, surface, skin, keep, incontinent, nutrition) can be used (NHS Improvement, 2018). Venous thromboembolism (VTE) assessment should be carried out, using questions such as:
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 College 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 informationF 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; 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 environment, understand their needs and determine who needs to be involved in their care. This is particularly important for inpatients awaiting discharge. GoalsGoals set for the patient will be based on the results of the assessment. The following questions can be useful:
It is best practice to use a SMART (specific, 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 (situation, background, assessment, recommendations) is useful. It is important to reassess patients if their status changes or as per the monitoring plan put in place.
Box 4. Disability warning signs
ACVPU = Alert, Confusion (new), response to Voice, Painful stimuli, Unconscious ConclusionThe 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 deterioration 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. Key points
References Benson A (2017) The A-G assessment tool (Airway, Breathing, Circulation, Disability, Exposure, Further information and Goals). Clinical Skills. Net Clinical Skills Limited. Cathala X, Costa A (2019) Anatomy and physiology. In: Moorley C (ed) A Guide to Your First Year in Nursing. London: Sage (in press). Cathala X, Moorley C (2018) Selecting intravenous fluids to manage fluid loss in critically ill patients. Nursing Times [online]; 114: 12, 41-44. Falk KM, Hudson SL (2016) Pain: The Fifth Vital Sign. Griffiths P et al (2018) Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. Health Services and Delivery Research; 6: 38. Kitsuta Y et al (2006) Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage. Prehospital and Disaster Medicine; 21: 3, 190-195. National Institute for Health and Care Excellence (2018) Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NHS Improvement (2018) Pressure Ulcer Core Curriculum. London: NHS Improvement. O’Driscoll BR et al (2017) BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax; 72: i1-i90. Resuscitation Council UK (2015) Resuscitation guidelines. The ABCDE approach. Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. Sansone CM et al (2017) Relationship between capillary refill time at triage and abnormal clinical condition: a prospective study. Open Nursing Journal; 11, 84-90. Smith GB et al (2017) Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units. International Journal of Obstetric Anesthesia; 30, 44-51. Williams B (2019) The National Early Warning Score 2 (NEWS2) in patients with hypercapnic respiratory failure. Clinical Medicine; 19: 1, 94-95. |
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