secondary assessment
TRANSCRIPT
K. A. V. Hewapathirana (RN, RM, BSc)
Senior Tutor
PBCN -Colombo
Secondary Assessment
Secondary Assessment
Is brief
Perform after the primary assessment & resuscitation
Is valuable for discovering occult problems in patients with a poor or confusing history
Goal of the secondary assessment is:-
To discover all other abnormalities or injuries that are not life threatening
F- Full set of vital signs / Focused adjuncts/ Facilitate family presence
G- Give comfort measures
H- History & head to toe assessment
I- Inspect posterior surfaces
Blood pressure
Pulse – rate / rhythm / quality
Central pulse Peripheral pulse
Apical Radial
Carotid Brachial
Femoral Posterior tibialis
Dorsalispedis
Temperature
Respiration- rate/ depth/ quality
Focused adjuncts For patients with significant abnormalities in the
primary assessment, consider performing the following interventions at this assessment and intervention process.
Cardiac monitoring Sp O2 End tidal CO2 monitoring Gastric tube - risk of aspiration
risk of respiratory compromise Indwelling catheter Laboratory studies Imaging studies – X-Rays
CT scanMRI
Need for tetanus immunization
Facilitate family presence
Family presence may reduce anxiety of the patient
Assess the family’s desire to present at the bedside
Source for assessment
Give comfort measure
Assess pain ( using PQRST )
{ Provocation , quality , region/radiation, severity , temporal factors }
Position of comfort if not contraindicated
Splint , elevate , injured extremities
Use age-appropriate distraction techniques
Administer pharmacologic therapy as ordered (analgesics , NSAID , narcotics )
History
History of present illness/ injury/ chief complaint, immunization, allergies, medications, past medical history, events surrounding the condition, diet.
Content & time of most recently ingested food, alcohol
Efforts to relieve symptoms ( home remedies , medication, physician visits)
Past medical history
General health status
Current or pre-existing disease/illness
Respiratory ,neurologic, endocrine, hepatic, haematological diseases or risk factors
Infections, immunosupre sion, autoimmune, psychological related conditions.
Recent trauma –blunt/ penetrating
Substance or alcohol use/abuse
Detoxification history
Smoking history
Last normal menstrual period –for female pts
Environmental exposures
Obesity, malnourishment, eating disorders history
Related situations for present problem or current event
Previous episodes – No
Yes- duration, date, Rx
Previous injury
Current medications Allergies – for medication
for foodothers
Immunization status – for tetanusfor childhood illnesses
Psychological / social / environmental factorsCollection of a complete social and psychological
history may be limited. However in some situations this information is essential.
Risk factors- smoking, substance use, psychiatric history Age appropriate behaviour Occupation
Hobbies
Family & support system
Responsibilities- self, family, occupational, community
Living accommodations- house, apartment, homeless
Head to toe assessmentA complete head to toe assessment is
necessary for all critically ill or injured patients .It is not required for patients with only minor injuries or symptoms related to one body system.
General appearanceBehaviourOdoursAcetone-indicative of ketosisGasoline-indicative of spilled fuelUrineFaeces
Metallic-indicative of blood loss
Chemicals
Others
Gait
Hygiene
Level of distress/ discomfort/ critically ill
Skin/ mucous membrane/ nail beds
Inspection
(Integrity, lacerations, ecchymosis, abrasions, puncture wounds, burns, foreign objects)
Colour
Pink, pallor, erythema, jaundice, cyanosis
Rash/ Lesions
Abscess formation
Cellulites, lymphagitis
Palpation
Moisture/ Turgor
Dry , moist, diaphoresis, edema
Cntd……
Temperature
Cool, cold, warm
Head & Face
InspectionSkin integrity, lacerations ,abrasions ,puncture
wounds ,burn , foreign objects
Ecchymosis- bilateral periorbital ecchymosis( black
eyes) may indicate basilar skull fracture
Oedema
Presence of pink or grey tissue-possible brain tissue damage
Facial features-symmetry/ asymmetry
Malocclusion of teeth
Palpation Bony deformity-depression , tenderness Open fracture Loose teeth
EyesInspection Skin integrity-lacerations ,ecchymosis, abrasions,
puncture wounds ,foreign objects Gross visual acuity Pupil size ,equally reaction to light Sclera/ conjunctiva-colour, bleeding ,excessive
tearing, discharges, foreign objects ,ulcerations Lid oedema Ptosis Excessive blinking or inability to open eyes Exopthalmus Contact lensess
Inspection Integrity, lacerations, ecchymosis, abrasions,
puncture wounds, burns, foreign objects Blood presence –external ear or canal Clear fluid –CSF leakage indicate an open skull
fracture. Ecchymos- behind ear over the mastoid bone-
battle’s sign –may indicative of basilar skull fracture
Exposed cartilage Purulent discharge External haematoma
Inspection
- skin integrity-lacerations ,ecchymosis, abrasions, puncture wounds, burns, foreign –objects
-bleeding/ discharges
-deformity/swelling
-Septal hematoma
rhinorrhoea-
-palpation
bony tenderness
deformity
Inspection
Skin integrity-lacerations, ecchymosis ,abrasions, puncture wounds,burns,foreign objects.
Oedema
Palpation
Tracheal position
Neck veins-distended/flat
Subcutaneous emphysema-may indicate disruption of trachea or bronchial tree
Step-off along cervical spine-tenderness or muscle spasm
Inspection
Accessory muscle use
Bony deformities
Skin integrity-lacerations ,abrasions puncture wounds, burns ,foreign objects.
Chest
Inspection
Accessory muscle use
Bony deformities
Skin integrity
Ecchymosis
Palpation
Tenderness
Crepitus
Deformity
Subcutaneous emphysema
Auscultation
Breath sounds-
Bilateral equality ( normal, decreased, absent)
Any adventitious sounds ( wheezes, rhonchi)
Dyspnoea
Heart sounds-
Muffled
Murmurs
Gallops
Abdomen
Inspection-
Laceration, Abrasion, Puncture wounds, burns, rashes, surgical scars
Palpation-
tenderness, soft, rigid, masses
Auscultation-
bowel sounds ( present, absent, hypo active, hyper active)
Pelvis/ Perineum
Inspection-
Skin integrity, bleeding(urethral, genital, rectal)
Genital lesions or discharges
Palpation-
Pelvic tenderness
Extremities
inspection
Skin integrity
Closed fractures
Open fractures
Deformities
Oedemas
Palpation
Tenderness
Instability
crepitus
Motor function
flexion /extension
Symmetry of strength
Range of motion
Sensory function
Sharp/dull
Circulatory status
Colour/skin temperature
Pulses distal to injury
Capillary refill
Posterior surfaces
patient’s back and posterior aspects of arms and legs
Should be evaluated for the presence of bleeding, abrasions ,wounds, haematomas, ecchymosis, rashes, lesions, oedema
The vertebral column
-tenderness ,deformity
Logroll the patient to maintain spinal alignment if there is any potential for spinal injury
Group AssignmentTo prepare a history taking format
• Individual Assignment
Physical assessment presentation of an emergency patient according to given format