The ABCDE Assessment in UK Nursing

ABCDE is the UK systematic assessment framework for acutely unwell patients. Resuscitation Council UK is the canonical source; the approach is used across NHS clinical settings and tested in NMC OSCE and CBT.

This chapter summarises the framework. For binding guidance on specific interventions at each letter, refer to Resuscitation Council UK and your trust’s local protocols.

A — Airway

Assess whether the patient’s airway is patent.

Look for:

• Patient speaking normally (suggests patent airway).
• Signs of obstruction: stridor, snoring, gurgling, paradoxical chest movement.
• Foreign body, swelling, blood, vomit.

Intervene:

• Position (head tilt-chin lift, jaw thrust if trauma).
• Suction if appropriate.
• Adjuncts (oropharyngeal or nasopharyngeal airway) if trained.
• Call for help (anaesthetics or critical care for definitive management).

Don’t move to B until airway is secured.

B — Breathing

Assess respiratory function.

Look, listen, feel:

• Respiratory rate.
• Depth and pattern.
• Use of accessory muscles, recession, paradox.
• Oxygen saturation.
• Chest expansion symmetry.
• Breath sounds.
• Trachea position.

Intervene:

• Apply oxygen at appropriate rate (refer to trust protocol and patient context).
• Position upright if appropriate.
• Treat reversible causes (bronchodilator for asthma/COPD, decompress tension pneumothorax).
• Reassess after intervention.

C — Circulation

Assess cardiovascular function.

Look, feel, check:

• Pulse rate, rhythm, volume.
• Blood pressure.
• Capillary refill time.
• Skin colour, temperature, sweating.
• Urine output if catheterised.
• Signs of bleeding.

Intervene:

• IV access (typically two large-bore cannulae for significant compromise).
• Take bloods including group and save where indicated.
• IV fluids if hypovolaemic (250-500 mL bolus, reassess).
• Treat reversible causes.

D — Disability

Assess neurological function.

Check:

• Level of consciousness using AVPU (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale.
• Pupil size and response.
• Blood glucose.
• Limb movement and sensation.

Intervene:

• Address hypoglycaemia urgently.
• Reposition for airway management if reduced consciousness.
• Escalate for any reduction in GCS, new neurological signs, or unresponsive patient.

E — Exposure

Look-feel-listen comprehensively.

Check:

• Full skin examination for rashes, injuries, signs of infection.
• Temperature.
• Abdominal examination if clinically relevant.
• Anything not yet assessed.

Maintain:

• Patient dignity throughout (cover when not actively examining).
• Warmth (hypothermia worsens many conditions).
• Privacy.

Common errors with ABCDE

Skipping letters. A nurse who notices an obvious circulation problem and jumps to C without checking A and B can miss the airway compromise that’s driving the cardiovascular failure.

Assessment without intervention. Recording observations at each letter without acting on the abnormalities. ABCDE is meant to be intervention-paced.

Forgetting to reassess. After each intervention, reassess. A patient who improved at B may worsen again, and the reassessment cycle continues.

Not calling for help. ABCDE is a framework for systematic response, not a substitute for senior input. Call for help early if the patient is deteriorating.

ABCDE and NEWS2 together

The two work together:

• NEWS2 identifies that deterioration is happening: the score triggers concern.
• ABCDE structures the assessment and intervention.
• SBAR communicates what you’ve found to the next clinician.

A high NEWS2 should trigger an ABCDE assessment. The findings from ABCDE inform the SBAR escalation. The cycle continues until the patient is stable or in higher-level care.

ABCDE in the OSCE

The OSCE Assessment station often presents an acutely unwell scenario where ABCDE is the right framework. Verbalise the framework as you go (“I’m now assessing A, airway. The patient is speaking normally, so the airway is patent. Moving to B, breathing.”).

Examiners reward visible systematic approach. The score sheet typically has tick boxes for each letter being assessed.

When ABCDE doesn’t apply

A stable patient in a routine context (a routine post-operative review, a chronic disease check-up, a discharge planning conversation) doesn’t need ABCDE. The framework is for acute presentations.

For routine stable patients, an assessment that covers physical, social, psychological and spiritual needs is more appropriate (covered briefly in Chapter 77).

The next chapter covers SBAR, the structured handover framework that follows ABCDE assessment.