Airway, breathing, circulation: Clinical decision making

The ABC acronym, which stands for Airway, Breathing, and Circulation, helps nurses prioritize patient care. This approach can be used to make clinical decisions when caring for several patients and to guide the care of one patient with multiple concerns.

Using the ABCs as a guide, nurses can rapidly make clinical decisions based on the severity of a patient's condition, ensuring the most critical issues are addressed first.

OK, let's start with A for airway, which involves evaluating whether the patient's airway is open, patent, and clear. This has the highest priority because without an open airway, oxygen can't reach the lungs, which can quickly lead to oxygen deprivation, brain injury, and eventually death.

Cues that indicate a compromised airway include noisy breathing like stridor, which is a high pitched whistling sound, gurgling or snoring respirations, choking, or being unable to speak.

Injuries that could impair the airway may present as blood or secretions in the mouth or throat, as well as facial fractures or swelling.

Additionally, if a patient is unconscious or tended, they may not be able to effectively maintain their own airway. If the patient's airway is secure, the next priority is B for breathing or the process of ventilation to support gas exchange.

Even with a clear airway, other conditions like chest trauma, pulmonary disease, or lung infections can impair breathing.

Cues that signal breathing impairment may include dyspnea or shortness of breath, a rapid or slow rate of breathing, nasal flaring, or use of accessory muscles like the sternocleidomastoid muscles in the neck, and color changes like pallor or cyanosis.

Sometimes a patient might assume the orthopnic or tripod position by leaning slightly forward with their arms propped up on an overbed table or their knees to help reduce the work of breathing.

In addition, auscultation may reveal adventitious lung sounds like wheezing or rales, or there could be an absence of lung sounds altogether.

Other findings include a tracheal shift as seen in a tension pneumothorax or paradoxical chest movement, where a section of the chest wall moves in the opposite direction compared to the rest of the chest during breathing, as seen with flail chest.

Palpation may reveal fractures or air under the tissue of the skin called subcutaneous emphysema. After ensuring a patient's breathing is effective, the focus shifts to C for circulation, or the movement of blood, oxygen, and nutrients essential for vital organs and tissues.

The most emergent circulatory problem is hemorrhage, since significant blood loss can impair cardiac output and lead to organ failure and death if not controlled.

Signs of hemorrhage can be overt, like active bleeding or ecchymosis, or less apparent when the bleeding is internal. Other cues of impaired circulation include a weak, thready pulse, changes in heart rate, rhythm, or heart sounds, as well as fluctuations in BP, prolonged capillary refill, and decreased skin temperature.

Patients may also present with lightheadedness, dizziness, or unusual fatigue. Finally, keep in mind that the exceptions to the ABC sequence are emergent situations when cardiopulmonary resuscitation is required or when massive uncontrolled external bleeding is present.

In these cases, addressing impaired circulation through hemorrhage control and chest compressions are the highest priority, and the order changes to circulation or compressions, airway, and breathing, also called CAB, to ensure blood flow to vital organs is maintained.

Now, let's look at a scenario where a nurse uses the ABCs to inform clinical decision making and prioritize care. Nurse Ebony is working triage in the emergency department when 3 patients arrive at the same time.

First is Wei, a 30-year-old who walked in with a forearm laceration sustained after falling off a motor scooter. The wound is oozing blood and Wey is holding a saturated towel over it.

His vital signs are heart rate 80 BPM, R 17 breaths per minute, BP 126/77 millimeters of mercury, and oxygen saturation 95% on room air.

The second patient is Tolulope, a 45-year-old who arrived via ambulance after suffering an asthma attack at the local state fair.

Audible wheezes can be heard, and she can speak a few words at a time. Her vital signs are heart rate 119 BPM, respirations 31 breaths per minute, BP 141/88 millimeters of mercury, and oxygen saturation 90% via non-rebreather mask.

The third patient is Chuck, a 75-year-old brought in by ambulance following an unwitnessed fall at home. He's currently unconscious and is making audible snoring noises as he breathes.

His vital signs are heart rate 110 BPM, respirations 8 breaths per minute, BP 89/58 millimeters of mercury, and oxygen saturation 89% via non-rebreather mask.

By following the ABCs, Nurse Ebony will rapidly gather information to inform clinical decision making and prioritize care.

Starting with A, Nurse Ebony observes that Wei's airway is open and doesn't require immediate attention. Tolulope's airway is also open since she can speak even if it's just a little, but her wheezing suggests airway edema that could obstruct her airway if it worsens.

Chuck, on the other hand, has snoring respirations, indicating his upper airway is partially obstructed, and he's having difficulty keeping his airway open due to being unconscious.

Next, for B, Nurse Ebony notes that Way's breathing is normal and requires no assistance. However, Tolulope's breathing is impaired, evidenced by tachypnia, audible wheezing, and low oxygen saturation.

As for Chuck, his oxygen saturation is also low, and his respirations are bradipnic, indicating breathing impairment in addition to his compromised airway.

Lastly, with C, Nurse Ebony knows that Wei's circulation is impacted due to his bleeding wound, but it's unlikely his hemorrhage is significant because his vital signs are stable.

As for Tolulope, her heart rate and BP are elevated, which is likely related to her anxiety and stress from the asthma attack.

Chuck is hypotensive and tachycardic, which could indicate shock from internal bleeding or neurological damage. Based on this information, Nurse Ebony prioritizes care for Chuck, Tolope, and Wey.

Due to Chuck's compromised airway and signs of potential shock, he's Nurse Ebony's highest priority. As such, she'll work with the healthcare team to secure his airway, continue supplemental oxygen, and investigate the source of his circulatory issues.

Tolulope is the second priority. Her severe asthma attack requires prompt attention to keep her airway open and manage her breathing.

Nurse Ebony will administer the prescribed bronchodilators and steroids to reduce swelling and open Tolulope's airway, along with continuing supplemental oxygen.

Wei is the last priority because his condition is more stable. Although his circulatory problem is less critical, it's necessary to control the bleeding and dress his wound.

Then Nurse Ebony will continue to monitor any delayed signs of ineffective perfusion due to his blood loss. All right, as a quick recap, assessment of airway, breathing and circulation, or ABCs for short, can be used to make emergent decisions and prioritize care.

By following the ABCs, nurses can address the most critical issues first, ensuring that each patient receives the appropriate level of care based on the severity of their condition.