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