In Nursing, we are so used to working with frameworks. One of the most important frameworks that nurses or those in medical practice use is the ABCDE framework. They help us prioritise our approach to patient care and serve as a good guidance as to what needs to be assessed and intervened first.
The ABCDE tool is used for the identification and prioritisation of patient problems. In stable patients, the use of this tool can be done very quickly. ABCDE is an acronym for Airway, Breathing, Circulation, Disability, and Exposure.
Using the ABCDE needs further training and additional skill. The framework itself also allows for integration of other assessment frameworks and clinical procedures. The Glasgow Coma Scale and ACVPU assessments which are used to assess the patient’s level of consciousness are also implemented within the ABCDE framework. Vital signs monitoring and the SBAR method which is a tool used to communicate to other colleagues in the field are also applied as well as many other assessment and clinical skills.
The Primary Survey can be used outside-hospital and in-hospital settings. Also, one must ensure to always use their clinical judgment and critical thinking skills. For example, before approaching a patient in public, always be sure that your environment is safe and that it is safe for you to help the individual as well.
Points to consider in using the ABCDE:
Initial assessments are done as well as regular re-assessments. Patients conditions may change from time-to-time or could deteriorate further which then addresses the need for changing the plan of care or adding additional interventions. When using the ABCDE framework, this must be done in a step-by-step / chronological order. If the problem is the airway (e.g. obstructed airway), then this must be addressed and treated first before moving to B for breathing or C for circulation.
The most critical areas or life threatening problems are to be treated first before moving to the next part of the assessment.
Always call for help early especially in emergency situations. We all work as a team and a pair of hands will always be very beneficial.
Use clinical judgment to treat. Each scenario is different and thus interventions can also vary depending on the cause of patient’s problems and overall situation. Follow institution policies and current standards care. The ABCDE framework is a tool to serve as a guide but can be useful only when done according to purpose and following best practices.
The Assessment Process
General Inspection - Even before you perform your ABCDE’s, you’ll already have a general impression of your patient by just simply using your senses. We may already see the patient’s skin colour (pink or cyanotic) or whether they are awake and conscious (or unconscious) even before reaching the bedside. The split seconds of using our senses already gives us a good picture of our patient which is really useful when we begin with letter A (for airway assessment).
Airway:
Assess for patency of airway. Is it clear? Is it partially obstructed or fully obstructed?
Are there secretions obstructing the airway? Any foreign object? Is the tongue obstructing the airway? Any vomitus? Any signs of bronchoconstriction or bronchospasms?
If the source of obstruction can be easily removed or cleared through changes in position (e.g. suction for secretions; turning sideways to clear from obstructing tongue and vomitus; performing head-tilt-chin lift manoeuvre or jaw thrusts), then remove to clear the airway. Use clinical judgment! It is important to know the cause of the obstruction using your assessment skills so that you’ll know what intervention is needed and what actions are contraindicated.
Partially obstructed airways can cause breath sounds that may give clues as to what is obstructing. A silent airway means that no air is passing through and therefore suspect complete obstruction.
Examples of breath sounds: snoring (could be caused by anatomical obstructions like the tongue partially obstructing the airway), stridor, wheeze (high pitched sound which may be due to bronchoconstriction), crackles, and silent.
Breathing:
Assess the rate, rhythm, depth and quality of respirations. Are both lungs expanding within each breath (bilateral chest movement)? Any deformities in the chest, or any tracheal deviations? Is the patient using accessory muscles when breathing?
Any shortness of breath? What is the O2 saturation?
Use clinical judgment to treat problems in breathing (e.g. high back rest positioning, oxygenation, nebulisation for asthma and etc.).
Circulation
Assess heart rate and pulses, blood pressure, capillary refill, and temperature which also includes assessing the warmth (or coldness) of the extremities. When palpating for the pulse, take note of the volume and rhythm.
Assess urine output.
Depending on what’s applicable for the situation and on assessment findings, use clinical judgment to treat (e.g. starting an intravenous line and IV fluid resuscitation, inotropic therapy, blood transfusion, catheter insertion and etc.)
Disability
Assess patient’s level of consciousness and examine the pupils. Are pupils equally round and reactive to light and accommodation (when using the penlight)? Is the patient conscious, coherent, and oriented to person, time and place?
What is the Glasgow Coma Scale (GCS) score? Is the patient fully awake? Or is the patient only responsive to voice? Is the patient only responsive to painful stimulus? Or is the patient completely unresponsive? -- ACVPU.
What is the blood glucose level?
Can the patient move his/her limbs?
Exposure (and Everything else!)
Check for wounds, bruising, oedema, skin ulcers, bleeding and other injuries. Keep patient warm and appropriately covered.
Identify other injuries and environmental threats.
Once the primary survey has been completed and the immediate problems already managed, the secondary survey takes place which involves assessing for further Signs and Symptoms, Allergies, Medications, Past medical history, Last meal and other Events associated to patient’s problems (SAMPLE). A head-to-toe examination may even be performed but always remember to assess and re-assess patients including the ABCDE as the condition could change. Patient’s status can either improve or deteriorate, and it is important to be clinically vigilant and to act early at all times.
Disclaimer:
The content in this blog is for informational purposes only and should not be taken as medical advice. It is always best to consult your doctor for medical questions.
If you are a healthcare provider, the content here should not be used to make any diagnosis, give advice or prescribe treatment as this blog is for informational and educational purposes only. Healthcare is an ever-changing field and each patient is unique. It is your responsibility as a healthcare provider to always refer to current care standards and practices.