ABCs of Emergency Nursing Care – Study Guide

In any life-threatening or emergency situation, always follow the ABCs:
🅰 Airway
🅱 Breathing
🅲 Circulation

🅰 AIRWAY

🔍 Ask Yourself: Is the patient’s airway open and clear?

🚫 Possible Problems:

• Obstruction of airway

  • Tongue, food, mucus, vomit

• Swelling (anaphylaxis, burns, trauma)

• Foreign body aspiration

• Facial or neck trauma

⚠ Signs & Symptoms:

• Noisy breathing (stridor, wheezing)

• Gasping or choking

• Cyanosis (blue lips/fingertips)

• Use of abdominal muscles or chest retraction

• Obstructed airflow from nose/mouth

• Grunting or snoring respirations

🛟 Treatment & Management:

• Reposition patient (Head-tilt/chin-lift unless spinal trauma is suspected)

• Jaw-thrust maneuver (if spinal injury suspected)

• Heimlich maneuver for choking

• Suctioning if secretions present

• Intubation (if unresponsive or cannot maintain airway)

🅱 BREATHING

🔍 Ask Yourself: Is the patient effectively breathing?

🚫 Possible Problems:

• Pulmonary edema

• Severe asthma

• Tension pneumothorax

• Flail chest

• Overdose causing respiratory depression

⚠ Signs & Symptoms:

• Tachypnea or Bradypnea

• Use of accessory muscles (neck, shoulders)

• Asymmetrical chest rise

• Displaced trachea (think: tension pneumothorax)

• Hypoventilation or hyperventilation

• Cyanosis or pallor

• Gasping, shallow or absent breathing

🛟 Treatment & Management:

• Administer oxygen (nasal cannula, mask, non-rebreather)

• Ventilate using a bag-valve mask if needed

• Position upright to ease breathing

• Insertion of chest tube if indicated (e.g., pneumothorax)

🅲 CIRCULATION

🔍 Ask Yourself: Is the patient’s blood circulating effectively to vital organs?

🚫 Possible Problems:

• Cardiac arrest

• Severe bleeding/hemorrhage

• Hypovolemic shock

• Myocardial infarction (MI)

• Sepsis

• Arrhythmias

⚠ Signs & Symptoms:

• No radial or carotid pulse

• Abnormal heart rate/BP

  • BP < 90/60 = concern

  • MAP < 65 = organ hypoperfusion

• Cool, clammy skin

• Pallor or mottling

• Capillary refill > 3 seconds

• Obvious bleeding

• Confusion/LOC changes (brain not perfused)

🛟 Treatment & Management:

• Start IV access (large bore) or IO access

• Administer fluids (NS/LR) and blood products

• Control bleeding (pressure, tourniquet, etc.)

• CPR if no pulse (initiate BLS/ACLS)

• Use defibrillator if in shockable rhythm (V-fib/V-tach)

📌 ABCs Prioritization Tips for NCLEX:

🧠 Remember:

✨ Quick Mnemonics:

• A – “Anything blocking air?”

• B – “Can the chest rise and fall?”

• C – “Is the blood moving?”