2.3 Secondary assessment techniques
3 min read•august 7, 2024
Secondary assessment techniques are crucial for gathering detailed patient information after the . These methods include obtaining a , collecting vital signs, and performing neurological checks to assess the patient's overall condition and identify specific health concerns.
Physical examination is another key component of secondary assessment. This involves a head-to-toe inspection, , and to detect injuries or abnormalities. Focused assessments based on the patient's chief complaint help prioritize interventions and guide further treatment decisions.
Patient History and Vitals
Gathering Information
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- Obtain a SAMPLE history from the patient or bystanders
- S: Signs and symptoms (chief complaint, onset, duration, severity)
- A: Allergies to medications, foods, or environmental factors
- M: Medications taken regularly or recently
- P: (illnesses, surgeries, hospitalizations)
- L: Last oral intake (food, drink, medications)
- E: Events leading up to the incident or illness
- Collect vital signs to assess the patient's overall condition
- Measure , , , and
- Compare vital signs to normal ranges for the patient's age and condition
- Perform a to determine the location, severity, and nature of pain
- Use a pain scale (numeric, visual, or verbal) to quantify pain intensity
- Ask about the quality of pain (sharp, dull, burning, aching) and any radiating pain
- Inquire about factors that alleviate or exacerbate the pain
Neurological Assessment
Evaluating Consciousness and Brain Function
- Utilize the (GCS) to assess the patient's level of consciousness
- Evaluate eye opening response (spontaneous, to voice, to pain, none)
- Assess verbal response (oriented, confused, inappropriate words, incomprehensible sounds, none)
- Determine motor response (obeys commands, localizes pain, withdraws from pain, flexion, extension, none)
- Calculate the total (3-15) to gauge the severity of neurological impairment
- Conduct a to identify any deficits or abnormalities
- Assess orientation to person, place, time, and situation
- Test memory by asking the patient to recall recent events or specific details
- Evaluate speech for clarity, coherence, and appropriateness
- Check for facial asymmetry, weakness, or drooping
- Test muscle strength, sensation, and coordination in all extremities
- Examine to light to assess brain stem function
- Check for pupil size, equality, and reactivity to light
- Note any abnormalities such as unequal pupils (anisocoria) or fixed, dilated pupils
Physical Examination
Conducting a Thorough Assessment
- Perform a head-to-toe examination to identify any visible injuries, deformities, or abnormalities
- Inspect the head, neck, chest, abdomen, pelvis, back, and extremities
- Palpate for tenderness, swelling, crepitus, or instability
- Auscultate the chest and abdomen for abnormal sounds (wheezes, crackles, absent bowel sounds)
- Conduct a based on the patient's chief complaint or
- Examine the affected body region or system in greater detail
- Look for signs of specific conditions (fractures, burns, lacerations, abdominal pain)
- Perform a in critical situations to quickly identify life-threatening injuries
- Check for major bleeding, airway obstruction, chest injuries, and neurological deficits
- Prioritize interventions based on the findings of the rapid assessment
- Assess and temperature to evaluate perfusion and circulation
- Look for pallor, (bluish discoloration), or flushing
- Check for cool, clammy skin or hot, dry skin
- Check to assess peripheral circulation
- Press on the nail bed or fingertip until it blanches, then release
- Normal capillary refill should occur within 2 seconds
- Listen to lung sounds to evaluate air movement and detect abnormalities
- Auscultate the chest bilaterally in the upper and lower lobes
- Listen for normal breath sounds, wheezes, crackles, or diminished sounds
- Perform an abdominal assessment to check for tenderness, distension, or rigidity
- Inspect the abdomen for visible abnormalities (scars, bruising, distension)
- Auscultate for bowel sounds in all four quadrants
- Palpate gently for tenderness, guarding, or masses
Key Terms to Review (28)
Active Listening: Active listening is a communication technique that involves fully concentrating, understanding, responding, and remembering what the speaker is saying. It goes beyond just hearing words; it requires engagement and feedback, ensuring the speaker feels heard and valued. This skill is crucial in various high-pressure situations, as it helps build trust, clarifies information, and supports effective decision-making.
Auscultation: Auscultation is the medical practice of listening to the internal sounds of the body, typically using a stethoscope, to assess the condition of various organs and systems. This technique is vital for monitoring health status, as it provides insights into vital signs such as heart and lung function. Auscultation plays a crucial role in interpreting physiological processes and identifying abnormalities, aiding in diagnostic decisions.
Blood Pressure: Blood pressure is the force exerted by circulating blood against the walls of blood vessels, typically measured in millimeters of mercury (mmHg). It's a vital sign that helps assess cardiovascular health and is essential for interpreting a person's overall health status, especially in the context of shock and secondary assessments. Monitoring blood pressure allows healthcare providers to evaluate how well the heart and blood vessels are functioning.
Capillary refill time: Capillary refill time is the duration it takes for color to return to a nail bed after it has been compressed, typically assessed as an indicator of peripheral perfusion and circulatory status. This measurement helps evaluate vital signs, indicating how well blood is circulating in the body, particularly in assessing shock conditions, understanding secondary assessment techniques, and guiding first aid interventions.
Charting: Charting is the systematic process of documenting patient information, observations, and care provided during a medical encounter. This practice ensures accurate communication among healthcare providers, tracks a patient’s progress over time, and serves as a legal record of the care administered. Effective charting is essential for maintaining continuity of care and enhancing patient safety.
Cyanosis: Cyanosis is a bluish or purplish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. This condition serves as an important indicator of underlying respiratory or circulatory issues, often requiring immediate attention in emergency situations such as choking, asthma attacks, and pediatric emergencies.
Edema: Edema is the medical term for swelling caused by excess fluid trapped in the body's tissues. This condition can be a common occurrence in various medical situations, particularly among older adults and during assessments of injuries or illnesses, as it may indicate underlying health issues or injuries.
Focused Assessment: Focused assessment is a targeted evaluation of a patient's specific condition or symptoms, often performed after an initial assessment to gather more detailed information. This approach allows responders to identify critical changes in a patient's condition quickly and decide on necessary interventions, ensuring that care is tailored to the individual's needs.
GCS score: The Glasgow Coma Scale (GCS) score is a clinical tool used to assess a patient's level of consciousness following a traumatic brain injury. It evaluates three aspects of responsiveness: eye opening, verbal response, and motor response, each contributing to a total score that helps determine the severity of brain injury and guides further medical intervention.
Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a clinical scale used to assess a person's level of consciousness after a brain injury by evaluating three aspects: eye opening, verbal response, and motor response. This scale helps emergency responders prioritize care and determine the severity of head injuries, which is crucial for patient assessment and history taking.
Head-to-toe assessment: A head-to-toe assessment is a systematic method used to evaluate a patient's overall health status by examining each part of the body from head to toe. This approach helps identify any abnormalities or potential medical issues, ensuring that all systems are reviewed and providing a comprehensive understanding of the patient's condition.
Mechanism of injury: The mechanism of injury refers to the specific way in which an injury occurs, encompassing the forces or events that lead to trauma. Understanding this concept is crucial for assessing the nature and severity of injuries, determining appropriate care, and anticipating potential complications during emergency situations.
Neurological check: A neurological check is an assessment used to evaluate a person's nervous system function, focusing on their level of consciousness, motor function, sensory function, and reflexes. This assessment is essential for identifying any changes in neurological status that may indicate a serious condition requiring immediate intervention. By conducting a neurological check, responders can gather crucial information that aids in determining the severity of an injury or illness and guide further treatment decisions.
Open-ended questions: Open-ended questions are inquiries that cannot be answered with a simple 'yes' or 'no'; instead, they require a more elaborate response that encourages the person to share more detailed information. This type of questioning is especially valuable in assessments, as it allows the responder to express their thoughts, feelings, and experiences in depth, facilitating a better understanding of their condition and needs.
Pain assessment: Pain assessment is the systematic process of evaluating a patient's pain to understand its intensity, quality, and impact on daily life. This evaluation is crucial in guiding treatment decisions and ensuring effective pain management, as it allows healthcare providers to identify specific pain characteristics and monitor changes over time.
Palpation: Palpation is a physical examination technique that involves using the hands to feel the body’s tissues, organs, and structures. This method is crucial in assessing various vital signs and conditions, helping healthcare providers gather important information about a patient’s health status. Through palpation, practitioners can detect abnormalities, tenderness, and other significant findings that inform diagnosis and treatment decisions.
Past Medical History: Past medical history refers to a comprehensive record of an individual's previous health conditions, surgeries, and treatments that can impact their current health status. This information is crucial in understanding a patient's overall health and making informed decisions during the secondary assessment process, as it can reveal potential risks or complications related to existing or previous medical issues.
Primary Survey: The primary survey is an essential first step in assessing a patient's condition in an emergency situation, focusing on identifying and managing immediate threats to life. It involves a systematic approach to check for responsiveness, airway, breathing, circulation, and any significant injuries, ensuring that the most critical issues are addressed promptly. This process is vital for prioritizing care and effectively guiding subsequent treatment decisions.
Pulse Rate: Pulse rate refers to the number of times the heart beats in one minute, typically measured in beats per minute (BPM). It is a vital sign that provides important insights into a person's cardiovascular health, physical condition, and overall well-being. Monitoring pulse rate is crucial for assessing the heart's efficiency and can indicate various health issues or changes in physical status.
Pupil Response: Pupil response refers to the way the pupils of the eyes react to light and changes in focus, indicating neurological function and overall health. It involves both constriction and dilation, serving as a vital sign in assessing an individual's condition during secondary assessments, especially when evaluating potential head injuries or neurological issues.
Rapid body survey: A rapid body survey is a quick, systematic examination of a patient to identify any life-threatening injuries or conditions. This assessment is crucial in emergency situations, as it helps first responders prioritize care and interventions based on the findings, ensuring that serious issues are addressed promptly before more detailed assessments are conducted.
Respiratory Rate: Respiratory rate is the number of breaths a person takes per minute, serving as a vital sign in assessing an individual's respiratory function and overall health. It helps indicate how well oxygen is being supplied to the body and how effectively carbon dioxide is being expelled. Abnormal respiratory rates can signal underlying health issues or distress, making it crucial for monitoring during various medical situations.
Sample History: Sample history refers to a systematic method of gathering essential information about a patient’s current condition and past medical history during the assessment process. It is crucial for understanding the patient's background, identifying potential causes of their symptoms, and determining appropriate treatment options. Collecting a sample history involves asking specific questions about the patient's medical history, medications, allergies, and any relevant family history that may impact their health status.
Secondary survey: The secondary survey is a systematic examination of a patient after the initial assessment has been completed, aimed at identifying any additional injuries or medical conditions that may not be immediately apparent. This process is crucial in providing comprehensive care and ensuring that all potential issues are addressed, especially in emergency situations where every detail can impact patient outcomes.
Skin color: Skin color refers to the pigmentation of a person's skin, which can vary widely due to genetic factors and environmental influences. In a medical context, assessing skin color is important as it can provide insights into a person's overall health, circulation, and potential underlying conditions.
Skin temperature: Skin temperature refers to the measure of heat at the surface of the skin, which can vary based on factors like blood flow, ambient temperature, and underlying health conditions. It serves as an important indicator of a person's physiological state, particularly during assessments for conditions such as shock, infection, or fever.
SOAP Notes: SOAP notes are a structured method of documentation used by healthcare providers to record patient information in a clear and organized manner. The acronym stands for Subjective, Objective, Assessment, and Plan, which helps ensure that all relevant details of a patient encounter are systematically documented. This method is crucial for effective communication among healthcare professionals and plays a key role in the documentation and handover processes, as well as in secondary assessment techniques.
Temperature: Temperature is a measure of how hot or cold something is, specifically referring to the degree of heat present in the body. In a medical context, temperature is a vital sign that can indicate various health conditions, making it essential for assessing an individual's overall well-being.