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.

Okay, 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 obtunded, 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 orthopneic, 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.