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From our readers…Know your A, B, C, and D’s for patients with progressive disease


“Something’s wrong. We have to fix it quickly!”

All of our training and experiences as nurses, such as my almost 30 years as a hospital-based RN, lead us to have this response to any unexpected negative situation. The A, B, C mnemonic for “Airway, Breathing, and Circulation” is a prime example of a means we use routinely to intervene quickly and effectively when things are going wrong.

Whether we work in hospitals, clinics, or other settings, we are often unprepared for those situations when we can’t “fix it”. My experience of having pulmonary hypertension and complications has broadened my perspective. Some diseases have no cure; others are treatable, but chronic and progressive until death. For those circumstances consider using the following A, B, C and D format and nursing diagnoses to provide the care your patients need.

A — Anxiety. Anxiety will most likely be present in varying degrees and at various times during disease progression or even during normal aging. It can start before or after diagnosis. In addition to concerns about dying and death, anxiety can also occur because of alterations in self-image from loss of accustomed roles in the home or at work.

Questions that may signal anxiety include, “When will my pain, shortness of breath, fatigue, weakness or other symptoms or complications happen or get worse again? Will I die the next time I get very sick? How am I going to live the rest of my life? When and how will I die? What will happen to my family when I am gone? Is there anything I can do to help them through this time in our lives?”

Consider the following nursing diagnoses when developing the care plan:

  • Anxiety
  • Deficient Knowledge
  • Disturbed Sleep Pattern
  • Altered Behavioral Patterns
  • Altered Mood States
  • Ineffective Coping
  • Disturbed Body Image
  • Powerlessness

B — Breathing. Dyspnea or other respiratory difficulties such as those associated with cardiopulmonary conditions may occur and can exacerbate anxiety.

Consider the following nursing diagnoses:

  • Ineffective Breathing Pattern
  • Impaired Gas Exchange
  • Ineffective Airway Clearance
  • Excess Fluid Volume
  • Risk for aspiration

C — Comfort. Maintaining patient comfort should be a high priority. That includes controlling pain, maintaining cleanliness and safety, positioning and other measures to maximize circulation and breathing effectiveness, and providing nutrition and hydration as desired and tolerated.

Consider the following nursing diagnoses:

  • Pain, Acute and/or Chronic
  • Activity Intolerance and/or Fatigue
  • Impaired Physical Mobility
  • Self Care Deficit: Impaired Ability to Perform Activities of Daily Living
  • Ineffective Health Maintenance
  • Imbalanced Nutrition: Less or More than Body Requirements
  • Fluid Volume Alteration: Deficit or Excess
  • Risk for Aspiration
  • Risk for Impaired Skin Integrity
  • Risk for Infection
  • Impaired Home Maintenance

D — Denial. Like anxiety, denial may be present in varying degrees and at various times during disease progression or even during normal aging. For instance, I have said, “Sometimes when I’m feeling better, I can almost convince myself that the whole thing is just a big fraud.” I change my mind when I have respiratory distress and extreme fatigue again. Some people simply refuse to believe their prognosis at all.

Consider the following nursing diagnoses:

    • Ineffective Therapeutic Regimen Management
    • Noncompliance


D — Dying and Death. Dying and death may occur over a period of hours, weeks, or even years. This process includes bereavement of patient, family, and caregivers. Discussion of the patient’s wishes for end-of-life care and documentation of advance directives should be part of the care planning process. Consider when, or if, hospice is indicated.

Consider the following nursing diagnoses:

  • Interrupted Family Process
  • Anticipatory Grieving
  • Spiritual Distress

Honesty is imperative

Honesty must play a role in nursing care plans based on the diagnoses. Be honest with your patient, the patient’s family members, and yourself about the expectations, feelings, and concerns for dying and death.

It is not uncommon for patients to ask how much time they have left to live. Our professional experience tells us that there is no way to know the answer to that question. In spite of that knowledge, I couldn’t help asking the question last April when my cardiologist said there was nothing else to be done, and to “get your affairs in order.” That was much harder to hear than his previous, “You’ll have setbacks, and one of those times you won’t bounce back.” Naturally, when I asked the question he said that he couldn’t foresee how much longer I would live. “You’ve already lived longer than any of us [including my pulmonologist and nephrologist] thought you would.” It is definitely acceptable to sometimes say, “I just don’t know”.

I am not giving up, but my body is wearing out. I am going to keep on doing what I can, with whatever I have, for as long as I’m still alive. I still have things to do, people to love, and love to receive. I will keep on living until I don’t.

Ellen Shoun is retired because of health issues and lives in Florence, Oregon. She worked at Peace Harbor Hospital in Florence for the last 16 years of her career.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

Selected references

Nursing Care Plan. NCP: end of life/hospice care. Accessed January 3, 2012.

1 Comment.

  • I loved the line” I will keep on living until I don’t”. Nurses need to deal with death as positively as possible. It’s a fact of life. The A,B,C,D’s were great advice.

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