Comprehensive A-G Assessment, ISBAR, and AIDET Report in Nursing

This assignment presents a comprehensive A-G assessment of a 45-year-old patient admitted to the ED due to a fall, detailing the patient's airway, breathing, circulation, disability, exposure, fluids, and glucose levels. The assessment reveals a patent airway, normal vital signs, and hyperglycemia (BGL 21.2 mmol/L). The assignment also includes an ISBAR (Identify, Situation, Background, Assessment, Recommendation) report, where a student nurse communicates the patient's condition to a senior nurse, highlighting the hyperglycemia and recommending a clinical review and ketone test. Additionally, an AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) framework is used to communicate with the patient. The student demonstrates the procedure for checking blood glucose levels, emphasizing hand hygiene and safety considerations.

A-G assessment:
A Airway is Patent, nil of obstruction. Patient able to talk in full sentence.
B Spo2 97% in RA. RR 22 normal and strong. There are no signs of wheezing or stridor on
escalation. No any sing of respiratory distress noted.
C Bp 124/80 mmHg. HR is 108 bpm which is regular and strong. His capillary refill >2
second. His hand warm to touch. no any sign of cyanosis present.
D Patient conscious and oriented. Pain scale is 0/10. Pupils is reactive to the light.
E Temp 37.5 degree Celsius. No IVC. Nil of oedema. There is no wound or injuries. No any
chest tube or IV inserted.
F No current IVf running. His intake is 2L of orange juice and 4 glasses of water. He noted
that he has been to toilet and did a big wee.
G BGL 21.2 mmol/L, which indicate hyperglycaemia. No sign of confusion.
ISBAR:
I: Hello X (name of senior nurse). My name is Deepana,I am a student RN. Is this Dr-Y? I am calling
from MMW about Mr Jo French, 45 years old in room 5 who was admitted to the ED.
S: I am calling for clinical review for Jo French as per the Clinical Emergency Response System (CERS).
The patient has hyperglycaemia. He is experiencing of some blurred vision increase frequency of
urination, thirst, hunger, fatigue and dizziness which indicate the hypoglycaemia.
B: Jo French is a 45 years old patient who was admitted to ED due to fall in his bathroom overnight
and hits his head but no loss of consciousness. He has no significant medical history, from the past
but his father has a history of heart disease. He was experiencing dizziness, blurry vision, weakness
and nausea before his fall.
A- Airway is Patent, nil of obstruction. Patient able to talk in full sentence.
B- Spo2 97% in RA. RR 22 normal and strong. There are no signs of wheezing or stridor on escalation.
No any sing of respiratory distress noted.
C- Bp 124/80 mmHg. HR is 108 bpm which is regular and strong. His capillary refill >2 second. His
hand warm to touch. no any sign of cyanosis present.
D- Patient conscious and oriented. Pain scale is 0/10. Pupils is reactive to the light.

E- Temp 37.5 degree Celsius. No IVC. Nil of oedema. There is no wound or injuries. No any chest tube
or IV inserted.
F- No current IVf running. His intake is 2L of orange juice and 4 glasses of water. He noted that he
has been to toilet and did a big wee.
G- BGL 21.2 mmol/L, which indicate hyperglycaemia. No sign of confusion.
R: I am calling for clinical review and I would appreciate clinical review within next 30 minute. Also, I
would like to recommend reassessment and ketone test for this patient. Is there anything would you
like me to do to prevent further deterioration before you arrive.
AIDET
A: Hello. How are you doing?
I: Hi, my name is . I will be your nurse today?
D: I am going to do A-G assessment which might take 20-25 minute. Is that okay? Also, I am going to
ask you some question regarding your health and if you have a question you ask me during the
assessment.
E: Can you please sit or lay in comfortable position. I am going to check your blood pressure. Then, I
am going to check your heart rhythm. I am going to check your oxygen saturation. I would like to
listen to your lungs sound. Do you have any pain? I am going to check your skin for any rushes or
other skin problems. I am going to check your circulation. I am going to check your pulse.
T: Thank you for letting me do an assessment. Please let me know if you need anything. The buzzer is
next to you.
Before starting the assessment, I ensure availability of all necessary equipment including gloves,
glucose monitor, test strips, BP monitor, alcohol wipe, spring loaded lancet, cotton wool etc. Before
checking patient, I first introduce myself to the patient and explain all the procedure to him. Then, I am
going to sanitize my hands and wear hand gloves.
For patient with any disease, it is necessary to ensure all the safety considerations. I clean the tip of one
finger of patient with alcohol wipe and enable it to dry. At that time, it was very necessary for me to ensure
that there is no sugar on the finger of patient from sweet, candy etc. as this will provide a wrong elevated
reading. After that, I prepared test strip and ensure that strip is still in date.
Then I loaded the strip into glucose monitor. At that time, the patient feels hesitated before I prick on his
finger. Then I communicate with the patient, and told him not to hesitate. I open the Lancet carefully and
prick the side of finger of patient with lancet.
After that, I squeeze the finger of patient so that the droplet of blood ooze out. I wipe away the very first
drop of blood and then again squeeze the finger in order to form another drop. I placed the second drop on
test strip so as to ensure that it covers this strip completely.
After that I gave the patient with a piece of cotton to stop bleeding. Then I safely dispose of the lancet, test
strip as well as the gloves in dustbin.

At last, I thank the patient to patiently sit it and allow me to complete the test appropriately.
I record the reading from blood sugar monitor and it depicts that the patient has hyperglycemia due to
which he feels dizziness, fatigue, thirst and hunger.
While completing all the procedure, one thing which I thing which I ensure is hand hygiene. In order to
protect patient and myself from any kind of infection, it is very necessary to take care of hand hygiene.
Washing or sanitize hands on continuous basis is very necessary to get defense against infection. In
managing any patient, safety is the first priority so, I first emphasize towards ensuring safety of patient and
sanitize may hands before checking blood glucose level of patient.