ABCDE Assessment for Student Nurses: What to Check and Why

Early deterioration is not always immediately obvious. A patient may be quieter than usual, speak in shorter sentences or say that they feel wrong before the full clinical picture is clear. The Airway, Breathing, Circulation, Disability and Exposure assessment, usually shortened to ABCDE, gives the team a consistent way to identify immediate threats without losing direction.

The point is not to race through five letters. It is to identify and respond to the most dangerous problem first, call for help early and return to reassess what has changed. Resuscitation Council UK advises treating life-threatening problems as they are found rather than completing the whole assessment before acting.

Think of ABCDE as: assess, act on immediate danger, continue, then reassess from A.

Why does ABCDE follow this order?

The order reflects priorities. A blocked airway can become fatal within minutes. Severe breathing failure can rapidly cause hypoxia. Circulatory failure threatens oxygen delivery to the brain, heart and other organs. Neurological change may be the result of problems already identified in A, B or C, or may point to a primary neurological, metabolic or medication-related cause. Exposure then helps you find important clues that are not obvious while the patient is covered.

This does not mean every patient will have a problem at every stage. It means you deliberately check for the threats most likely to cause rapid harm first.

Before you begin

Start with safety, appropriate infection-prevention precautions and a rapid first impression. Introduce yourself if the situation allows, confirm the patient’s identity and explain what you are doing.

Ask a simple question such as “How are you feeling?” A clear, normal reply gives you useful information immediately. It strongly suggests that air is currently moving through the upper airway, that the patient can generate enough airflow to speak and that cerebral perfusion is sufficient for them to respond. It does not prove that everything is normal.

Before you become focused on the observation machine, look at the patient. Ask yourself:

• Do they look acutely unwell?
• Are they sitting unusually still or struggling to breathe?
• Are they pale, clammy, cyanosed or mottled?
• Can they speak normally?
• Are they behaving differently from earlier?
• Is there obvious bleeding, vomit or another immediate problem?

If the patient is unresponsive and is not breathing normally, this is no longer a routine ABCDE assessment. Summon emergency help and begin the appropriate resuscitation response within your training and local policy. As a student, never delay escalation because you are trying to complete the assessment alone.

A: Airway

The airway question is simple: can air move freely from the mouth and nose towards the lungs?

The ability to speak normally strongly suggests that the airway is currently patent, although partial or evolving obstruction can still develop. Listen to the voice as well as the words. New hoarseness, difficulty speaking, reduced voice volume or an inability to complete a sentence can matter.

What should you look and listen for?

• snoring
• gurgling
• stridor
• vomit, blood or visible secretions
• facial, tongue or neck swelling
• foreign material where visible
• reduced consciousness with loss of airway tone
• signs of burns or inhalation injury where relevant

Why? No amount of oxygen therapy can compensate for an airway that air cannot pass through. Airway obstruction therefore takes priority over the later stages of the assessment.

Stridor is particularly concerning because it suggests upper-airway narrowing. Facial or tongue swelling after exposure to an allergen should also trigger urgent escalation because the airway can worsen quickly.

What can a student do?

Call for experienced help early, stay with the patient and perform simple actions only if you have been trained and are permitted to do so. Positioning, suction, airway manoeuvres and airway adjuncts are separate clinical skills and should not be treated as interchangeable.

If an intervention is made, reassess the airway immediately. Do not assume that because it improved once, it will remain safe.

B: Breathing

Once the airway is open, ask whether the patient is ventilating and oxygenating effectively. Breathing assessment is much more than looking at the oxygen saturation.

Start with respiratory rate

Count it properly rather than estimating. Respiratory rate can change early in deterioration and a rising rate may appear before blood pressure or oxygen saturation changes significantly.

Also look at:

• depth of breathing
• regularity and pattern
• whether both sides of the chest appear to move similarly
• use of accessory muscles
• nasal flaring where relevant
• ability to speak in full sentences
• signs of fatigue or exhaustion
• skin colour and central cyanosis
• pain that is limiting inspiration

Why? A patient can maintain a reasonable saturation for a time while working extremely hard to breathe. Increasing effort, a rising respiratory rate or new exhaustion can therefore be more concerning than one apparently reassuring number.

Check oxygen saturation properly

Check SpO2, but ask whether you trust the reading. Movement, cold peripheries, poor perfusion, nail products and poor probe positioning can all interfere with pulse oximetry.

Record whether the patient is breathing room air or receiving oxygen. If oxygen is in use, note the device, flow rate or prescribed setting and the target saturation documented for that patient.

For most acutely ill adults, commonly used UK guidance targets an oxygen saturation of 94 to 98%. For many patients who are at risk of hypercapnic respiratory failure, a target of 88 to 92% may be prescribed while further assessment, including blood gases where indicated, takes place.

Do not treat those ranges as permission to independently alter oxygen outside your competence or local policy. Follow the patient’s prescribed target and local emergency oxygen guidance, and escalate if they are outside target or clinically deteriorating.

What else may be assessed?

Depending on your training and the clinical area, the wider team may assess chest expansion, tracheal position, breath sounds and percussion note, and review chest drains or other respiratory equipment. If you are trained to auscultate, connect what you hear with the rest of the assessment rather than naming a sound in isolation.

Examples of immediate breathing problems the team may need to consider include severe asthma, pulmonary oedema, pneumothorax, pneumonia, pulmonary embolism or respiratory depression. As a student, your role is to recognise the concerning pattern and escalate, not independently make the final diagnosis.

C: Circulation

Circulation asks whether blood is moving effectively enough to deliver oxygen to the tissues.

Check the pulse

Assess the rate and rhythm, and where appropriate note its strength. A fast pulse may occur with pain, fever, anxiety, hypovolaemia, sepsis or arrhythmia. A slow pulse may be normal for some people but can also be clinically significant in the right context.

Measure blood pressure and look at the trend

A blood-pressure reading is more useful when you compare it with the patient’s previous readings and usual baseline. A patient whose systolic pressure has fallen substantially may be deteriorating even if the number has not yet crossed a familiar threshold.

Why? Falling pressure can reflect reduced circulating volume, vasodilation, cardiac dysfunction or another cause of impaired circulation. The number alone does not tell you which one.

Look at peripheral perfusion

Assess capillary refill according to local practice and consider:

• skin temperature
• pallor
• mottling
• clamminess or sweating
• peripheral colour
• new confusion or restlessness

Cold peripheries and prolonged capillary refill can suggest poor peripheral perfusion, although temperature and other factors can affect the finding.

Look for blood and fluid loss

Check for obvious bleeding and consider less obvious losses such as vomiting, diarrhoea, surgical drains or high stoma output. Review fluid balance and urine output where these are being monitored.

Reduced urine output can be an important sign of deterioration because the kidneys are sensitive to reduced perfusion. Do not diagnose hypovolaemia or acute kidney injury from urine output alone, but do recognise a falling trend and escalate it.

What might happen next?

Depending on the situation, the registered and medical team may establish intravenous access, obtain blood tests, measure lactate, perform an ECG, give prescribed fluids or blood products and investigate the cause of shock or bleeding. Participate only within your competence and supervision.

After any intervention, reassess pulse, blood pressure, perfusion, consciousness and the rest of ABCDE.

D: Disability

Disability is a rapid assessment of neurological function. A change in consciousness can result from a primary neurological problem, but it can also be caused by hypoxia, poor circulation, hypoglycaemia, infection, medicines, seizures or metabolic disturbance.

Assess consciousness

A commonly used rapid assessment is ACVPU:

• A: Alert
• C: new Confusion
• V: responds to Voice
• P: responds to Pain
• U: Unresponsive

New confusion matters. It can be an early manifestation of acute illness and is specifically recognised within NEWS2.

Where a more detailed neurological assessment is required, the Glasgow Coma Scale may be used by staff who are trained to perform it. Record the individual eye, verbal and motor components rather than relying on the total alone.

Check blood glucose

Hypoglycaemia is a reversible cause of altered behaviour, reduced consciousness and seizures, which is why glucose belongs in a rapid neurological assessment when indicated.

Check pupils and look for focal change

Depending on the situation, assess pupil size and reaction and look for new:

• facial asymmetry
• limb weakness
• speech disturbance
• seizure activity
• unusual agitation or drowsiness

Also think about medicines. Opioids, sedatives and other central nervous system depressants may contribute to reduced consciousness or respiratory depression.

Why does trend matter? A patient changing from Alert to new Confusion can be more clinically important than a person who has a stable long-term neurological impairment. Always compare with their usual baseline when possible.

E: Exposure

Exposure means looking for important information that may otherwise remain hidden, while protecting the patient’s dignity, privacy and temperature.

Check temperature and examine as much of the patient as is clinically necessary. Depending on the situation, look for:

• rashes or non-blanching skin changes
• wounds or signs of infection
• obvious or concealed bleeding
• oedema or swelling
• abdominal distension or tenderness where assessment is appropriate
• drains, stomas and their output
• pressure damage
• line or device problems
• limb changes
• the back and dependent areas when clinically indicated

Why? The clue that explains deterioration may not be visible from the end of the bed. A rash, leaking drain, surgical wound problem, concealed blood loss or high-output stoma can change the clinical picture completely.

Re-cover the patient promptly and keep them warm. Exposure is not permission to leave a vulnerable patient unnecessarily uncovered.

Bring the wider information together

Review relevant notes, prescriptions, allergies, fluid balance, recent observations, laboratory results and the patient’s own concerns. Ask what has changed since the last assessment.

ABCDE is a cycle, not a one-off checklist

ABCDE does not finish when you reach E. After an intervention or change in care, return to A and reassess.

Ask:

• Is the airway still safe?
• Has respiratory rate or effort changed?
• Is SpO2 moving towards the prescribed target?
• Has pulse, blood pressure or perfusion improved?
• Is consciousness better, worse or unchanged?
• Did the intervention actually work?

This repeated assessment is important because deterioration is dynamic. A patient may improve, remain unchanged or develop a new problem while you are caring for them.

Where does NEWS2 fit?

NEWS2, the National Early Warning Score 2, is widely used in UK acute care to support recognition of deterioration. It scores physiological observations including:

• respiratory rate
• oxygen saturation
• whether supplemental oxygen is being given
• systolic blood pressure
• pulse
• temperature
• consciousness, including new confusion

The score then links to a local escalation response.

NEWS2 and ABCDE do different jobs. NEWS2 helps quantify abnormal physiology and trends. ABCDE provides a structured way to assess and respond to the deteriorating patient in front of you.

A low NEWS2 score does not overrule significant clinical concern. NICE guidance on deterioration also recognises that escalation should be triggered by clinical concern as well as physiological scoring systems.

Use the NEWS2 chart and escalation protocol approved in your organisation. Scottish students may encounter NHS Education for Scotland resources alongside their local board policy.

Worked example 1: noisy airway after vomiting

You enter the bay and hear a previously drowsy patient making a wet gurgling sound after vomiting.

Your priority is not to take a full set of observations first. The sound suggests that the airway may be contaminated or partially obstructed. Call for help, assess the airway immediately and use only the airway actions you are trained and permitted to perform.

Once the immediate airway problem has been addressed, continue through B, C, D and E and then reassess from A.

Placement lesson: the most abnormal number on the monitor is not always the first problem.

Worked example 2: breathless but the saturation looks acceptable

A patient with an acute respiratory illness has an SpO2 of 95%, but their respiratory rate has risen from 18 to 30 breaths per minute. They are using accessory muscles and can now speak only a few words at a time.

The saturation should not reassure you. The patient is working much harder to breathe and may be tiring. Check their oxygen device and prescribed target, complete the breathing assessment within your competence and escalate promptly.

Placement lesson: interpret SpO2 alongside respiratory rate, effort, speech and the overall clinical picture.

Worked example 3: the blood pressure is falling

A post-operative patient has a systolic blood pressure of 102 mmHg. That number may not look dramatically low on its own, but earlier readings were around 140 mmHg. Their pulse is increasing, hands are cool and urine output has fallen.

The trend is concerning. Reassess circulation, look for bleeding or other losses, review fluid balance and escalate to the registered nurse and appropriate clinical team.

Placement lesson: deterioration often appears as a pattern of changes rather than one extreme value.

Worked example 4: new confusion

An older patient who was orientated earlier in the shift becomes suddenly confused and drowsy.

Do not jump straight to “delirium” and stop there. Return to ABCDE. Check airway and breathing, assess circulation, check glucose during Disability, review temperature and look for other evidence of acute illness during Exposure.

New confusion can be associated with hypoxia, infection, poor perfusion, hypoglycaemia, medicines and many other causes. The job at this point is to recognise deterioration, identify immediate threats and escalate.

Placement lesson: a neurological change may be caused by a problem elsewhere in ABCDE.

Common ABCDE mistakes

• Trying to finish the whole assessment before treating an immediate threat.
• Taking observations before looking at the patient.
• Assuming that speaking proves the airway will remain safe.
• Using SpO2 as the entire breathing assessment.
• Estimating respiratory rate instead of counting it.
• Ignoring the oxygen device, flow or prescribed target.
• Looking at one blood-pressure reading without checking the trend.
• Forgetting urine output and fluid losses when assessing circulation.
• Recording a consciousness score without asking whether it has changed from baseline.
• Forgetting blood glucose in an appropriate patient with altered consciousness.
• Exposing the patient unnecessarily or failing to re-cover them.
• Thinking a low NEWS2 score means clinical concern can be ignored.
• Completing ABCDE once and not reassessing after an intervention.
• Waiting until the end of the assessment to call for help despite obvious deterioration.

How to escalate what you have found

When you are concerned, say so clearly. You do not need to have diagnosed the cause before escalating.

An SBAR handover might sound like:

Situation: “I’m concerned about Mr Patel in bed 4. His breathing has worsened over the last 20 minutes.”

Background: “He was admitted with pneumonia and is receiving oxygen.”

Assessment: “His airway is currently clear. Respiratory rate is 32, he is using accessory muscles and his saturation is 90% on the prescribed oxygen. Blood pressure is also lower than earlier.”

Recommendation: “Could you review him now, please?”

That is much more useful than saying only, “His NEWS is high.”

Your role as a student nurse

Your role depends on your stage of learning, assessed competence, supervision, university requirements and local policy.

Within your competence, you can:

• recognise that a patient looks different or unwell
• begin a structured ABCDE assessment
• obtain accurate observations
• compare findings with previous observations and baseline
• identify immediate concerns
• call for help early
• communicate findings using SBAR
• remain with the deteriorating patient
• assist with interventions you are trained and supervised to perform
• reassess after interventions
• document findings, escalation and response accurately

You are not expected to diagnose or independently manage a deteriorating patient. The NMC Code requires professionals to work within competence, preserve safety, keep clear records and make timely referrals when care or treatment is needed. As a student, you are developing towards those standards under appropriate supervision.

A safe student is not the person who quietly completes every box. It is the person who recognises when the patient needs more help and says so clearly.

The bit worth remembering

ABCDE is not five observations. It is a way of thinking in order of immediate threat.

1. Look at the patient.
2. Assess A, then B, then C, then D, then E.
3. Treat or escalate life-threatening problems as you find them.
4. Use NEWS2 to support, not replace, clinical judgement.
5. After anything changes, go back to A and reassess.

If something feels wrong, escalate. You do not need to wait for the score to give you permission to be concerned.

References

British Thoracic Society (2017) BTS guideline for oxygen use in adults in healthcare and emergency settings. Available at: British Thoracic Society emergency oxygen guideline.

National Institute for Health and Care Excellence (NICE) (2007) Acutely ill adults in hospital: recognising and responding to deterioration. Clinical guideline CG50. Available at: NICE CG50.

NHS Education for Scotland (NES) (n.d.) Deteriorating adult. NMAHP critical care resources. Available at: NHS Education for Scotland deteriorating adult resources.

Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at: NMC Code.

Resuscitation Council UK (2024) The ABCDE approach. Updated July 2024. Available at: Resuscitation Council UK ABCDE approach.

Royal College of Physicians (2017) National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Available at: Royal College of Physicians NEWS2.

This article is for education and placement preparation. Always follow the escalation pathway, oxygen guidance, observation policy and supervision requirements used in your placement area.