Master Airway Breathing Circulation (ABCs) Nursing

When assessing a patient’s airway, looking for possible airway obstruction is the highest priority. If the patient responds with a normal voice, that is an indication that the airway is patent. The patient’s airway can be clear if the patient is speaking normally. In a partially obstructed airway, air entry is diminished and often noisy. A completely obstructed airway will be present with no air movement or sound at the mouth or nose.

“See-saw” respirations are a pattern of breathing seen in partial or complete airway obstruction. Airway obstruction causes the chest to contract during inhaling and to expand during exhaling, which is the opposite of how it should normally move.

Stridor or wheezing is a loud, high-pitched and harsh respiratory sound. This suggests partial airway obstruction. Snoring may often be a sign of airway obstruction.

The normal respiratory rate in adults is between 12 – 20 breaths/minute. A high respiratory rate is an indication that the patient may be deteriorating.

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 breath becomes more and more difficult. In adults, an observation of abdominal breathing is also an indication that breathing is labored.

Inadequate oxygenation of the blood leads to cyanosis or blue discoloration of the skin and mucous membranes. Other general signs of respiratory distress include sweating and abdominal breathing.

Inspecting the skin should give the healthcare provider clues of any circulatory problems. Inadequate oxygenation of the blood leads to cyanosis or blue discoloration of the skin and mucous membranes. Temperature of skin should also be noted.

Checking the patient’s capillary refill time (CRT) is a simple way to check circulation. To check the 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.

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 health care provider should assess if the 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 a low blood pressure is often a late sign in the deteriorating patient and can be an adverse clinical sign.

A rapid ‘‘look, listen and feel” of the patient should take about 20-30 seconds and will often be a fast indication to 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.

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.

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.