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ABC in Nursing - Assessment & Priority
ABC in Nursing – Airway, Breathing, Circulation
The ABCs of nursing are a mnemonic that nurses can use to assist them remember the most important actions to take when prioritizing patient care. When prioritizing care, one must decide which needs must be attended to right once and which can wait until a later time due to less urgency. Maslow’s hierarchy of needs theory is utilized by nurses to prioritize patients and determine which patient needs to be seen first.
Airway, breathing, and circulation (ABC), which are physiological components required for the body to survive and contribute to a person’s level of health, are included in Maslow’s hierarchy of needs. A quick evaluation of life-threatening situations in terms of priority can be made by observing ABCs.
A stands for airway assessment, which involves checking for airway obstruction, which can be detected by stridor, a changing voice sound, and “see-saw” respirations. B stands for breathing assessment and includes checking for cyanosis, using accessory muscles for breathing, and an irregular respiratory rate. C stands for circulation, looking for changes in the color of the hands and fingers, an unusual capillary refill time, and a drop in consciousness (LOC).
When making an initial assessment, take into account a quick “see, listen, and feel” observation. Moreover, any obstruction involving the ABCs needs to be treated immediately. It should be highlighted that patient needs linked to maintaining a patent airway are always priority in prioritizing test questions, and that the ABCs should always be taken into account. You will be pointed in the right direction by this.
AIRWAY ASSESSMENT
Problems with the patient’s airways that prohibit them from breathing or getting enough oxygen are referred to as airway difficulties. The patient’s breathing airways become constricted, obstructed, or swollen as a result of these obstructions.
Potential Causes are Food blockages, Throat swelling, Foreign objects, and Chocking hazards/small toys
Change in Voice
The top goal when examining a patient’s airway is to check for any potential obstructions. An indicator that the airway is patent is if the patient responds with a normal voice. If the patient is speaking normally, the airway may be clean. Air entry is reduced and frequently noisy in a partially blocked airway. There will be no air movement or sound at the mouth or nose and a totally blocked airway.
“See-saw” Respirations
When an airway is completely or partially blocked, “see-saw” respirations are a common breathing pattern. Contrary to how it should usually move, airway blockage causes the chest to expand during exhalation and contract during inhalation.
Stridor
A loud, high-pitched, and harsh respiratory sound is stridor, often known as wheezing. This may indicate some airway blockage. A frequent indicator of airway blockage is snoring.
BREATHING ASSESSMENT
The focus of breathing problems is on respiratory and ventilation problems. Many problems revolve around oxygen utilization. Fundamentally, this refers to how well individuals get enough oxygen into their lungs and blood. It also emphasizes how well patients expel toxic CO2 and oxygen from their bodies.
An example would be when a patient has respiratory problems, lung illness, infections, asthma, allergies, inflammation, etc.
12–20 breaths per minute is the normal respiratory rate.
Adults typically breathe 12 to 20 times each minute on average. A rapid breathing rate is a sign that the patient might be becoming worse.
Use of Accessory Muscles in Respiration
Accessory muscles are additional muscles that can help increase the amount of air that is inspired. These muscles are used to increase the volume and rate of respiration. Patients may appear as though they are pausing for breath between words, as the effort to breathe becomes more and more difficult. In adults, an observation of abdominal breathing is also an indication that breathing is labored.
Cyanosis
Cyanosis, or blue staining of the skin and mucous membranes, is caused by insufficient oxygenation of the blood. Abdominal breathing and perspiration are two additional typical indicators of respiratory distress.
When assessing patients breathing it’s essential to look for signs of breathing difficulty. Basically, you want to look for visual signs and listen for sounds that indicate potential breathing/respiratory distress. This includes color changes of the face/skin, grunting, nose flaring, wheezing, and supplemental body positioning due to oxygen issues. Finally, check the patient’s pulse oximetry to indicate abnormalities that cause/lead to respiratory issues. Abnormal blood oxygen levels may indicate problematic oxygen saturation of the blood.
Consequently, shortness of breath, confusion, and restlessness are potential signs of hypoxemia (low blood oxygen).
CIRCULATION ASSESSMENT
Circulatory assessment involves patients dealing with insufficient blood circulation. Circulatory problems result from various complications including physical occlusions, blood clots, diabetes, obesity, anemia, hemoglobin issues, etc.
Basically, poor blood circulation leads to reduced blood flow and this can cause individuals to experience physical pain, muscle cramps, numbness, and tingling/stinking pains. However, this may also cause strokes, heart attacks, or other severe complications in extreme cases.
Color of Hands and Digits
Inspecting the skin will give the healthcare provider clues about any circulatory problems. Inadequate oxygenation of the blood leads to cyanosis or bluish discoloration of the skin and mucous membranes. The temperature of the skin should also be noted. In this case, the peripheries will be cold.
Normal Capillary Refill Time: 2 Seconds
Checking the patient’s capillary refill time (CRT) is the easiest way to check circulation. To check the capillary refill time (CRT), the patient’s hand should be at the level of their heart. The healthcare provider should apply cutaneous pressure for 5 seconds with enough pressure to cause blanching. Time how long it takes for the skin to return to the color of the surrounding skin after releasing the pressure. The normal value for CRT is usually < 2 seconds. A prolonged CRT may be an indication of poor peripheral perfusion.
Decreased LOC
A rapid assessment of the patient’s level of consciousness (LOC) is used to determine the patient’s condition. Using the AVPU system to assess, the healthcare provider should assess if the patient is awake (A), responding to voice (V), responding to pain (P), or unresponsive (U). The healthcare provider should take a set of vitals as soon as possible. Taking the patient’s blood pressure will give clues, as low blood pressure is often a late sign in a deteriorating patient and can be an adverse clinical sign.
CONSIDERATIONS
Initial ‘Look, Listen, and Feel” Assessment
A rapid ‘‘look, listen, and feel” of the patient should take about 20-30 seconds and will often be a fast indication if a patient is critically ill and there is a need for emergency help. Asking the patient to respond to a question, listening to the breathing, and feeling the patient’s skin are all part of this rapid assessment.
Emergency Treatment
Airway obstruction is a medical emergency. Emergency help should be called immediately. Airway obstruction left untreated can rapidly lead to cardiac arrest, hypoxia, brain damage, or death. If the patient is unconscious, unresponsive, and is not breathing normally, CPR should be initiated according to the resuscitation guidelines.
Prioritization in Exam Questions
On nursing exams, there will often be questions regarding the prioritization of patients. Often these questions will ask, “Which patient is a priority?” Patients with problems regarding airway, breathing and circulation should always be the priority, and it should always be in that order. First priority is the airway, next is breathing, then circulation. Keeping in mind that this is the guideline for prioritizing care, this will direct you to the correct option.
Assessment and Treatment
Nurses must simultaneously assess and care for patients who have airway breathing, and circulatory problems. In other words, treatment is necessary concurrently with a patient’s assessment rather than following it. This is due to the fact that individuals with conditions related to the ABCs require quick care and assistance. So, nurses are better able to stop or lessen subsequent medical problems the quicker a patient receives therapy.
Giving outstanding patient care involves both assessment and treatment. Examine the procedures and order of importance for treating various respiratory, circulatory, and airway problems. This guarantees that you’ll correctly carry out the care plans required to provide suitable medical care to individuals in need. When managing several patients, make sure to prioritize each one based on their medical condition. The highest risk/priority patients might so receive rapid care.
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