advice regarding ABC's please.

Esme12, ASN, BSN, RN · Jan 19, 2012

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 · Jan 19, 2012

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."

katiebry1031 · Jan 19, 2012

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 :)

NCRNMDM, ASN, RN · Jan 21, 2012

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.