ABCD approach
Airway
Breathing
Circulation
Disability
Count the respiratory rate. The normal rate is 12–20 breaths min
Assess the depth of each breath, the pattern (rhythm) of respiration and whether chest expansion is equal on both sides.
Look, listen and feel for the general signs of respiratory distress: sweating, central cyanosis,
In acute respiratory failure, aim to maintain an oxygen saturation of 94–98%
Provide high-concentration oxygen using a mask with oxygen reservoir
Look for the sign of airway obstruction
Assess the limb temperature by feeling the patient’s hands: are they cool or warm?
Count the patient’s pulse rate listening to the heart with a stethoscope
Look at the colour of the hands and digits: are they blue, pink, pale
Measure the patient’s blood pressure
Look for other signs of a poor cardiac output, such as reduced conscious level
Measure the blood glucose to exclude hypoglycaemia
Nurse unconscious patients in the lateral position if their airway is not protected.
Examine the pupils (size, equality and reaction to light).
Is a systematic approach to the immediate assessment and treatment of critically ill or injured patients.