advice regarding ABC's please.

Students Student Assist

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i know this is highest priorty when it comes to assessment on a pt, but i was just a little confused. so even if the diagnosis has nothing to do with airway, ventilation, or respiratory etc. this will be the first thing you assess regarding of the situation when a patient presents with a problem?

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

ALWAYS.....If they aren't breathing they won't be healing. Many different diagnosis may be amplified by a breathing or circulation problem or airway problem.

B/P, HR, Pulse, Saturation, capillary refill....

nurseprnRN, BSN, RN

1 Article; 5,115 Posts

seriously, yes, you always assess subjective feelings ("i feel short of breath/my chest feels heavy/tight/etc.") and objective findings like breath sounds, respiratory mechanics, and diagnostic results (like spo2 or abgs if available). even if your findings are within normal limits, that's still useful data and may make it possible to rule out some things, or at least document that they aren't very bad.

i used to tell my students they had to learn cardiac and pulmonary physiology because they would use them almost every day of their working lives. why? because lots of our patients don't have kidneys, some don't even have brains, but by gawd if they don't have hearts and/or lungs they are dead people and we don't have to bother with them.:nurse: as the engineers in my family always say, "intuitively obvious to the casual observer." :D

katiebry1031

58 Posts

makes complete sense. after i posted this, i had a duh moment. its the joys of nursing school that makes us overanalyze every possible situation. thanks :)

It will be the first thing you assess, but some of it can be done quickly. When you walk into the room to get vital signs what do you do? You look at the patient to see if he is breathing; you check to see if he is pink (or race appropriate) or cyanotic, or if he has another abnormal coloring to his skin; you note the depth, rate, and ease of his breathing, and you listen to see if you can hear any loud or obvious adventitious breath sounds. If all of that checks out, and appears normal, you move on to taking your vital signs. You check the BP, heart rate, RR, oxygen saturation, temperature, and pain level. You may also go ahead and listen to breath sounds, check the capillary refill, listen to the apical heart rhythm, assess heart sounds, and check radial and pedal pulses at this time. By the time you've done all this, you have a clear picture of the basic ABCs. You know what the vital signs are, how the breath sounds are, how the heart sounds are, and you have a clear picture of the patient's airway, breathing, and circulation.

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