Secondary assessment

K. A. V. Hewapathirana (RN, RM, BSc)
Senior Tutor
PBCN -Colombo

1. K. A. V. Hewapathirana (RN, RM, BSc) Senior Tutor PBCN -Colombo Secondary Assessment

2. Secondary Assessment Is brief Perform after the primary assessment & resuscitation Is valuable for discovering occult problems in patients with a poor or confusing history

3. Goal of the secondary assessment is:- To discover all other abnormalities or injuries that are not life threatening

4. A useful mnemonic 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

5. F Blood pressure Pulse – rate / rhythm / quality Central pulse Peripheral pulse Apical Radial Carotid Brachial Femoral Posterior tibialis Dorsalis pedis Temperature Respiration- rate/ depth/ quality

6. F 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 scan MRI Need for tetanus immunization

7. F Facilitate family presence Family presence may reduce anxiety of the patient Assess the family’s desire to present at the bedside Source for assessment

8. G 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 )

9. H 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)

10. 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

11. 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, R x Previous injury

12. Current medications Allergies – for medication for food others Immunization status – for tetanus for childhood illnesses Psychological / social / environmental factors Collection 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

13. Hobbies Family & support system Responsibilities- self, family, occupational, community Living accommodations- house, apartment, homeless

14. Head to toe assessment A 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 appearance Behaviour Odours Acetone-indicative of ketosis Gasoline-indicative of spilled fuel Urine Faeces

15. Metallic-indicative of blood loss Chemicals Others Gait Hygiene Level of distress/ discomfort/ critically ill

16. 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

17. Cntd …… Temperature Cool, cold, warm

18. Head & Face Inspection Skin 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

19. Palpation Bony deformity-depression , tenderness Open fracture Loose teeth Eyes Inspection 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

20. 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 Ears

21. Inspection - skin integrity-lacerations , ecchymosis , abrasions, puncture wounds, burns, foreign –objects -bleeding/ discharges -deformity/swelling - Septal hematoma rhinorrhoea - -palpation b ony tenderness deformity Nose

22. 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 Neck

23. Inspection Accessory muscle use Bony deformities Skin integrity-lacerations ,abrasions puncture wounds, burns ,foreign objects. chest

24. Chest Inspection Accessory muscle use Bony deformities Skin integrity Ecchymosis Palpation Tenderness Crepitus Deformity Subcutaneous emphysema

25. Auscultation Breath sounds- Bilateral equality ( normal, decreased, absent) Any adventitious sounds ( wheezes, rhonchi ) Dyspnoea Heart sounds- Muffled Murmurs Gallops

26. Abdomen Inspection- Laceration, Abrasion, Puncture wounds, burns, rashes, surgical scars Palpation- tenderness, soft, rigid, masses Auscultation- bowel sounds ( present, absent, hypo active, hyper active)

27. Pelvis/ Perineum Inspection- Skin integrity, bleeding(urethral, genital, rectal) Genital lesions or discharges Palpation- Pelvic tenderness

28. Extremities inspection Skin integrity Closed fractures Open fractures Deformities Oedemas Palpation Tenderness Instability crepitus

29. 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

30. 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

31. Group Assignment To prepare a history taking format Individual Assignment Physical assessment presentation of an emergency patient according to given format Assignments

32. Thank You