For young children, the ABCs are the building blocks of their education—forming the foundation for everything they are going to learn in the years to come. The same goes for nurses; the ABCs of nursing provide nurses with a systematic way to address their patients’ most pressing needs.
Understanding the ABCs of Nursing Care
The ABCs of nursing are known as an assessment method nurses can use to diagnose and treat patients with critical injuries or severe illness. According to RNNetwork.com, ABC stands for airway, breathing, and circulation, and this method provides nurses with a pathway for prioritizing care and addressing the needs of patients in emergency situations.
Importance of ABCs in Nursing
Knowing the ABCs in nursing and being able to use this method effectively is incredibly important. The ABCs in nursing may help nurses:
- Quickly identify the needs of the patient.
- Provide critical care that can reduce the severity of their injury or even help save the patient’s life.
- Prioritize the needs of the patient.
Breaking Down the ABCs: Airway, Breathing, Circulation
The three components of the ABCs of nursing are airway, breathing, and circulation. According to this rapid assessment, nurses should first inspect the patient’s airway to see if there is an obstruction or another issue that needs to be addressed. After the airway has been evaluated, nurses should prioritize the patient’s breathing. During this phase, nurses should observe the patient and determine if there is a normal breathing pattern in place. After airway and breathing have been addressed, nurses should then focus on circulation. By taking note of the color of the patient’s hands and feet and their level of consciousness, they can quickly evaluate the individual’s current level of blood circulation in the body.
Airway
The first—and perhaps most critical—component of the ABC method is airway. In an emergency situation, whether the patient is suffering from a severe illness or a critical injury, nurses should prioritize the airway and determine if anything should be done to help clear the airway for the patient.
There are three distinct steps nurses should take when assessing the patient’s airway:
Identifying Changes in Voice
Listening to the patient’s voice and determining if there are sound changes could help a nurse quickly see if the airway is obstructed. According to Picmonic, the following voice changes are indicative of airway obstruction:
- No sound – If a patient cannot make any sound, the airway is likely to be fully obstructed, and this must be cleared immediately to allow the patient to breathe once again.
- Low voice or noisy airway – This may be indicative of a partial airway obstruction and must be treated as a higher priority in order to restore the patient’s ability to breathe normally.
- Normal voice – If the patient can speak normally, the airway is likely clear and free from obstruction.
Recognizing “See-Saw” Respirations
If the nurse is not able to determine if the airway is obstructed using the sound of the patient’s voice, the next step is to begin looking at the pattern of breathing near the chest. The lungs will make “see-saw” respirations if the airway is either partially or fully obstructed. “See-saw” respirations are contradictory to normal lung movements, and when they are taking place, the lungs contract when the patient inhales and expand when they exhale. It is a drastic and sudden respiration pattern that is easily recognized by trained and experienced nurses.
Detecting Stridor
Finally, nurses should then check to see if the patient is experiencing stridor. Stridor is often described as a high-pitched wheezing sound that is exacerbated when the patient tries to inhale. Stridor may occur as the result of a blocked or obstructed airway.
Breathing
If the patient has been found to have a clear airway free of obstruction, nurses must move on to the breathing assessment. During this component of the assessment, they will further analyze the patient’s breathing pattern and determine if additional measures need to take place to stabilize the patient. For example, a patient who is having trouble breathing as a result of chronic pneumonia may need oxygen in order to regulate breathing and improve the patient’s vital signs.
Understanding the Normal Respiratory Rate
The first component of the breathing assessment is to determine the patient’s respiratory rate. The average adult should have a respiratory rate between 12 and 20 breaths per minute. If a patient has an accelerated respiratory rate, it is a sign they may be in distress and that their health is rapidly deteriorating. Oxygen, medication, or ventilation may be necessary if a patient’s respiratory rate is too high.
Recognizing the Use of Accessory Muscles in Respiration
Humans rely on accessory muscles to increase the amount of air and oxygen they are taking in when they are having trouble breathing. For example, an individual who has just completed a rigorous workout may use additional muscles in order to catch their breath. While this may be a normal, temporary experience, patients who are in distress or poor health may be relying too heavily on their accessory muscles to attempt to breathe normally.
During this portion of the ABC assessment, nurses should check to see if the patient is:
- Pausing between words in order to breathe.
- Using abdominal muscles in order to breathe.
Identifying Cyanosis
Cyanosis occurs when an individual is not breathing normally and, therefore, is not getting enough oxygen into their circulation system. The most common signs and symptoms of cyanosis include blue discoloration of the skin, excessive sweating, or heavy breathing that utilizes the abdominal muscles. If cyanosis occurs, patients may require supplemental oxygen.
Circulation
After the patient’s airway and breathing have been evaluated, nurses should then prioritize circulation, which is the final component of this rapid assessment method. Poor circulation may quickly lead to a decline in a patient’s health, putting them at risk of serious complications or even death.
As part of the circulation assessment, nurses should begin:
Analyzing the Color of Hands and Digits
One of the quickest ways to determine if the patient is experiencing circulation issues is to look at the skin color of their hands, fingers, feet, and toes. If there is not enough oxygen in the blood, the patient’s skin may turn a blue color. In addition, their hands, feet, and digits may be cool to the touch.
Importance of Normal Capillary Refill Time
Nurses should then check the individual’s capillary refill time, or CRT. This is the amount of time it takes for blood to resume flowing in a particular area after pressure has been applied. In a healthy, normal adult, the CRT should be approximately 2 seconds. During the ABC assessment, if the CRT is longer than 2 seconds, nurses may need to take steps to address the circulation issues.
Detecting Decreased LOC
Finally, nurses should evaluate the individual’s level of consciousness, or LOC. LOC can be quickly assessed by:
- Checking to see if the patient is awake
- Verifying that the patient can respond to voice
- Determining if the patient can respond to pain
- Making note if the patient is unresponsive
In the event of a decreased LOC, nurses should immediately take the patient’s vital signs and begin administering the proper emergency care.
Essential Considerations While Mastering the ABCs
While learning how to master the ABCs and prioritize patient care, nurses should consider the following:
The ‘Look, Listen, and Feel’ Approach
The “Look, Listen, and Feel” approach is an incredibly quick assessment method nurses can rely on if they are faced with an emergency situation in which a patient may require immediate care. This method takes about 20 or 30 seconds to complete and requires the nurse to:
- Look at the patient and ask a question to see if they are responsive.
- Listen to the patient’s breathing pattern.
- Feel the patient’s skin to check for cool temperature or low CRT.
Prioritizing Emergency Treatment
In the event that a patient does require emergency care, nurses should quickly prioritize treatment and contact any additional medical professionals who can help. If the airway is obstructed, the obstruction should be removed as swiftly as possible. If the airway is clear, but the patient is unresponsive or having difficulty breathing, nurses should begin administering CPR until additional medical professionals arrive on the scene to provide the patient with the treatment they require.
Develop an Advanced Nursing Skillset at Post University
Regardless of the stage of your career or your current nursing specialization, you may find that an advanced degree allows you to improve your nursing skills. At Post University, we offer a Registered Nurse to Bachelor of Science in Nursing as well as a Master of Science in Nursing, both of which could provide you with the advanced nursing skills useful in today’s dynamic healthcare industry.
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