The ABCs of nursing care address patients' most critical and immediate needs. Nurses can prevent serious health consequences and save lives by systematically using these components.
As nurses, we play a vital role in promoting patient well-being. And in emergency situations, we’re one of the first caregivers at the bedside, making our knowledge of the ABCs of nursing care essential.
The ABCs of nursing provide a systematic method to prioritize the initial assessment of critically ill or injured patients. Being able to look at an emergency and quickly determine what steps come first by working through these areas is critical. The ABCs acronym represents three central components: airway, breathing, and circulation.
In emergencies, it’s vital to act swiftly to ensure that the patient’s airway is open, they are breathing adequately, and their circulation is maintained. The goal should be early detection and treatment of issues with the patient, even before a cause is identified.
These components are vital because they address patients’ most urgent needs and serve as a foundation for supporting life. Compromising the ABCs of nursing care can lead to severe health complications or even fatal consequences. However, once a patient is stabilized, you can then proceed with a head-to-toe assessment.
Airway
When the airway is compromised, the patient can experience oxygen deprivation, which can be life-threatening.
Airway care encompasses various factors that can impact its patency, or how open and unobstructed it is. These include:
- Physical obstruction: Physical objects or substances can block the airway. Obstruction is most common in choking situations and for patients with impaired swallowing.
- Swelling and inflammation: Allergic reactions, injuries, or infections can lead to swelling and inflammation of the airway, which can constrict airflow.
- Muscle relaxation: Some medications or medical conditions can cause muscle relaxation in the throat. Airway collapse can follow muscle relaxation, creating more complications to a patient’s breathing.
To ensure the protection and care of the airway, it is essential to take the following critical steps:
- Assess the airway: The first step in airway management is to assess for patency. Ensure that the airway is clear and unobstructed.
- Remove obstructions: Take immediate action if there is a visible obstruction. Removal of the blockage may include the Heimlich maneuver or abdominal thrusts and back blows.
- Positioning: Proper patient head and neck positioning using the head-tilt-lift maneuver keeps the airway open.
- Suction: When there are excessive secretions or mucus, use suction to maintain a clear airway.
- Intubation: Endotracheal intubation and mechanical ventilation may be necessary when patients cannot maintain their airway independently.
When assessing the patient, remember to observe signs of obstruction or compromise to the airway. These include: the inability to speak or make sounds; gurgling or snoring noises; decreased or absent breath sounds; high-pitched noisy breathing (stridor); bluish skin or lips (cyanosis); and accessory muscle use (indicates an increased effort to breathe).
Breathing
Adequate and effective breathing is necessary for the oxygenation of organs and tissues. Lung disease, trauma, or systemic conditions can cause breathing difficulties.
As the second major component of the ABCs of nursing care, the following elements are essential when assessing a patient’s breathing:
- Respiratory rate and effort: Rapid, shallow breathing or using accessory muscles indicates signs of respiratory distress.
- Breath sounds: Abnormal breath sounds, such as wheezing or crackles, can indicate underlying lung problems.
- Oxygen saturation: A pulse oximeter can be used to monitor oxygen saturation.
Effective breathing care requires several steps such as the use of supportive equipment and medications. By taking the following measures and working alongside other interdisciplinary teams, you can stabilize your patient’s respiratory function:
- Assess breathing: Assess the patient’s respiratory rate, depth, and effort.
- Administer oxygen: Give supplemental oxygen when oxygen levels are low.
- Medications: In some cases, medications such as bronchodilators or steroids are ordered and given.
- Ventilatory support: Patients with severe respiratory distress may require mechanical ventilation through a ventilator.
- Chest X-rays and other diagnostic tests: Assist in carrying out orders for X-rays or arterial blood gases to identify the underlying cause of breathing difficulties.
It’s important to note indications of complications or distress in your patient’s breathing. This includes increased respiratory rate; accessory muscle use; shallow or labored breathing; abnormal breath sounds; cyanosis; decreased oxygen saturation; or altered mental status.
Circulation
Blood flow delivers oxygen and nutrients to cells while removing waste products. A disruption in circulation can lead to organ failure and even death.
Like the airway and breathing components, there are essential elements involved when assessing a patient’s circulation. These include:
- Heart rate and rhythm: A rapid or irregular heartbeat can indicate circulatory problems.
- Blood pressure: Blood pressure shows how much force the heart uses to pump blood through the circulatory system.
- Peripheral pulses: The quality and strength of pulses in the extremities indicate how well blood flows in that extremity.
With circulation care, taking the following steps can help ensure your patient’s circulation is stabilized:
- Assess circulation: Assess heart rate, rhythm, blood pressure, and peripheral pulses. Address any abnormalities promptly.
- Cardiopulmonary resuscitation (CPR): In cardiac arrest or circulatory failure cases, nurses may need to perform CPR to maintain circulation and oxygen delivery.
- Intravenous access: Establishing intravenous (IV) access allows for administering fluids, medications, and blood products to support circulation.
- Cardiac monitoring: Continuous cardiac (heart) monitoring is essential for patients with cardiac issues.
- Blood transfusions: In cases of severe blood loss, blood transfusions may be necessary to restore circulation.
- Medications: Medications may be required to support the heart and circulation. Common medications are antiarrhythmics, vasopressors, atropine, and sodium bicarbonate.
Complications related to circulation may be easily detected or more subtle. Indicators include rapid and irregular heart rate; low blood pressure; weak or absent peripheral pulses; pale or mottled skin; cool extremities; altered mental status; and active bleeding.
By using the ABCs of nursing as a fundamental framework in practice, nurses and other healthcare workers can provide life-saving assessments and care.
Learn more about the ABCs of nursing and other vital nursing skills through Nurse.com's catalog of CE courses.
