4.3 Initial and Emergency Assessment

The Primary Survey or ABCCS assessment (airway, breathing, circulation, consciousness, safety) is the first assessment you will do when you meet your patient. This assessment is repeated whenever you suspect or recognize that your patient’s status has become, or is becoming, unstable.

For example, if you assess that your patient is short of breath (dyspneic) with an increased respiration rate (tachypneic), then you should proceed with an ABCCS assessment and a focused respiratory assessment with appropriate interventions.

The ABCCS assessment includes the steps in Checklist 1 below.

Checklist 1: Initial and Emergency Assessment (Primary Survey)
Disclaimer: Always review and follow your hospital’s policy regarding this specific skill.

Steps

 Additional Information
A—Airway

  • Is the patient’s airway compromised?
 Does the patient’s position need to be changed?

If patient is choking on thick secretions, consider oral suctioning (check suction equipment).
B—Breathing

  • Assess rate and ease of breathing.
  • Assess the effectiveness of the oxygen delivery.
 Is the oxygen flow connection intact? Is the rate, flow, and percentage as ordered?

Based on your assessment, consider the need for potential oxygen supplementation.
C—Circulation

  • Assess for the presence of a radial pulse.
  • Assess skin color, moisture, and temperature for signs of decreased tissue perfusion (pale, dusky, cool, or clammy skin).
 Note whether the pulse is too fast, too slow, or absent.

If a radial pulse is not detectable, check for a carotid pulse.

If no pulse is present, call for help and start CPR.
C—Consciousness

  • Check the patient’s level of consciousness (LOC).
 Is the patient alert, drowsy, disoriented, restless, agitated, unconscious?

Note if there is a change from the patient’s normal or previously noted LOC.
S—Safety

  • Ensure the patient is safe and free from risk of harm or injury at all times.
 Check for name band and allergy band.

Check oxygen saturation level.

Check that suction is working.

Check brakes on the bed, bed rail position (up, if required), bed is at the appropriate level, and call bell is within reach.

Are there any fall risk indicators?

Are there any dysphagia (difficulty swallowing) guidelines, or should there be some requested?
Report and document assessment findings and related health problems according to agency policy.
Data source: Clinical Procedures for Safer Patient Care copyright © 2015 by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

Critical Thinking Exercises

  1. Initial assessment of your patient reveals that the patient is having trouble speaking. What would be your next steps?
  2. What is included in the safety check on your unit? Is there anything that is not listed here?

Attribution

This chapter contains material taken from Clinical Procedures for Safer Patient Care by Glynda Rees Doyle and Jodie Anita McCutcheon and is licensed under a Creative Commons Attribution 4.0 International License.

License

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Nursing Physical Assessment Copyright © 2024 by Barbara Gawron and Meenu James is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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