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SECONDARY ASSESSMENT

LESSON 11. SECONDARY ASSESSMENT. Introduction. With no immediate threats to life, obtain the history and conduct a secondary assessment Obtain the patient’s vital signs and perform a physical examination The secondary assessment reveals additional information and problems

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SECONDARY ASSESSMENT

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  1. LESSON 11 SECONDARY ASSESSMENT

  2. Introduction • With no immediate threats to life, obtain the history and conduct a secondary assessment • Obtain the patient’s vital signs and perform a physical examination • The secondary assessment reveals additional information and problems • Continue to reassess the patient to ensure treatment is effective and that the patient’s condition is not worsening

  3. Patient History

  4. Patient History • Patient’s history is gained from patient or others • Begin by asking about the patient’s chief complaint • Although history focuses on specific injury or chief complaint, it should be complete • With responsive medical patients, you may take history before performing physical examination • With trauma patients and any unresponsive patient, perform physical examination first

  5. Taking a History • Talk to a responsive patient • With an unresponsive patient, talk to family members or others at the scene about what they know or saw • Look for medical alert insignia or other medical identification • In the home, look for medication bottles and a Vial of Life

  6. Taking a History (continued) • With trauma patient, assess forces involved • When taking history of a responsive patient with a sudden illness, ask fully about the patient’s situation to learn possible causes • Look for clues in the environment

  7. SAMPLE S = Signs and symptoms A = Allergies M = Medications P = Pertinent past history L = Last food or drink E = Events

  8. Additional Guidelinesfor History • If patient is unresponsive, ask family members or bystanders • Check scene for clues of what may have happened • Consider environment • Consider patient’s age • When additional EMS personnel arrive, give them information you gathered

  9. Age Variations in History • When taking the history and performing the secondary assessment, consider the patient’s life stage • For pediatric patients: • Assess an infant’s pulse at brachial artery • Use capillary refill as an indicator of adequate blood flow in infants and children younger than 6 • Use distracting measures and other actions to help gain the child’s trust • For geriatric patients: • Help the patient obtain eye glasses and hearing aids for improved communication • Accept that taking the history may take more time

  10. Secondary Assessment • After the history, unless you are now providing critical patient care, continue patient assessment • Take the patient’s vital signs • Perform a physical examination

  11. Vital Signs • Some EMRcheck patient’s vital signs • Vitals signs assessed include: • Breathing rate, rhythm, depth and ease • Pulse rate, rhythm and strength • Skin color, temperature and condition • Pupil size, equality and reaction to light • Blood pressure

  12. Importance of Vital Signs • Vital signs reveal additional information about condition • Changes in vital signs, from the baseline vital signs, are important and should be documented • Changes may show deterioration or improvement with treatment • Vital signs vary significantly among different individuals • Vital signs are affected by stress, activity and other variables

  13. Normal Vital Signs

  14. Assessing Respiration • Don’t tell a responsive patient that you are assessing breathing • Count respirations while holding wrist draped across chest as if taking a pulse • Observe or feel for the chest rising and falling (1 cycle = 1 breath)

  15. Assessing Respiration(continued) • Count number of breaths in 30 seconds and multiply by 2 • Note whether patient is making an effort to breathe, is short of breath or is using accessory muscles of neck and abdomen in breathing

  16. Characteristics of Respiratory Distress • Gasping or wheezing • Very fast or slow respiratory rate • Very shallow or very deep breathing • Shortness of breath, difficulty speaking

  17. Assessing Pulse • Have a responsive patient sit or lie down • Take a radial pulse in an adult or child • If no radial pulse, take carotid pulse in an adult or brachial pulse in a child • Always take brachial pulse in an infant • Count the beats for 30 seconds and multiply by 2 • Note strength of pulse (strong or weak) • Note rhythm of pulse (regular or irregular)

  18. Characteristics of Possible Circulation Problem • Very fast or very slow pulse • Very weak or strong, bounding pulse • Very weak and fast pulse (thready pulse) may indicate shock • Irregular rhythm may indicate a cardiac problem • Unequal pulses at different sites

  19. Assessing Skin Temperature and Condition • Assess skin temperature using back of hand on skin • Assess skin color • Assess skin moisture • In a young child, assess capillary refill

  20. Skin Characteristics That May Indicate a Problem • Skin temperature • Unusual coloration • Skin condition • Capillary refill time >2 seconds may indicate shock or diminished blood flow

  21. Assessing Pupils • Assess size of patient’s pupils • Assess the pupils for equality • Assess reactivity to light

  22. Assessing Pupils (continued) Pupil characteristics that may indicate a problem: • Dilated or constricted pupils • Unequal pupils • Non-reactive pupils

  23. Blood Pressure • When heart contracts, pressure is higher (systolic pressure) • Pressure falls lower when heart relaxes between beats (diastolic pressure) • Blood pressure is recorded as systolic pressure over diastolic pressure

  24. Blood Pressure (continued) • Some EMRs are trained to take blood pressure • Blood pressure is force of blood pressing against arterial wall from heart’s pumping action • Blood pressure indicates level of perfusion

  25. Skill: Measuring Blood Pressure by Auscultation

  26. Repeated Blood Pressure • It is difficult to interpret blood pressure because of wide variation among individuals • Repeated measurements may show a possible trend in patient’s condition • A drop in blood pressure in shock usually develops as a late sign

  27. Measuring Blood Pressure by Palpation • If you don’t have a stethoscope or the scene is noisy, measure systolic blood pressure by palpation • While palpating radial pulse, inflate cuff 30 mmHg beyond the point where you stop feeling pulse • While watching gauge, open valve to slowly deflate cuff • Note pressure when you feel radial pulse return • Record pressure as systolic pressure and include word ‘palpated’ (e.g., “130 palpated” or “130/P”)

  28. Physical Examination • Unless you are caring for a life-threatening condition, perform a physical examination • Purpose is to find and assess additional signs and symptoms of illness or injury • Because patients are often anxious about being examined, provide emotional support

  29. Physical Examination (continued) • Information gained from examination may help you care for patient and be of value to arriving EMS personnel • Complete rapid trauma assessment of unresponsive patient or a patient with a significant MOI • Perform focused physical examination of responsive medical patient or a trauma patient with only a minor injury

  30. When Performing a Physical Examination • Allow responsive patient to remain in position he/she finds most comfortable • Ask responsive patient for consent to do physical examination • Don’t start with a painful area

  31. When Performing a Physical Examination (continued) • Watch for facial expression or stiffening of body part • In responsive patient, begin with area of chief complaint and examine other body areas only as appropriate • With unresponsive patient, examine patient from head to toe in a systematic manner • If you find life-threatening problem at any time, treat it immediately

  32. When Performing a Physical Examination (continued) • Sign: an objective observation or measurement such as warm skin or a deformed extremity • Symptom: a subjective observation reported by the patient, such as pain or nausea

  33. Use SystematicHead-To-Toe Approach • Begin at head because injuries here are more likely to be serious than injuries elsewhere • With responsive children, begin at feet and work up body • Look and palpate for signs and symptoms throughout body – compare one side of body to other when appropriate

  34. DOTS for Trauma Patients D = Deformities O = Open injuries T = Tenderness (pain) S = Swelling

  35. DCAP-BTLS Memory Aid D = Deformities C = Contusions A = Abrasions P = Punctures/Penetrations B = Burns T = Tenderness L = Lacerations S = Swelling

  36. Check Head and Neck • Skull • Eyes • Ears • Nose • Breathing • Mouth • Neck

  37. Check Chest • Deformity? • Wounds? • Tenderness? • Bleeding? • Use of accessory muscles? • Equal chest rise?

  38. Check Abdomen • Rigidity? • Pain? • Bleeding?

  39. Back • Unless head or spinal injury is suspected, roll patient onto side to examine back • If head or neck injury is suspected, don’t move patient but slide your gloved hand under back • Sweep entire lower back, looking at fingertips of your gloved hands for any bleeding • Treat any tenderness, swelling or deformity of lower part of spine as a sign of spinal injury and don’t move patient

  40. Check Hips and Pelvis • Tenderness? • Instability? • Incontinence? • Priapism?

  41. Check Lower Extremities • Bleeding? Asymmetry? Deformity? Pain? • Normal movement, sensation, temperature? • Circulation?

  42. Check Upper Extremities • Bleeding? Deformity? Pain? • Medial alert identification? • Normal movement, sensation, temperature? • Circulation?

  43. Reassessment • Continue to assess while awaiting additional EMS resources and giving care • Calm and reassure patient while reassessing breathing and circulation and repeating vital signs andphysical examination • Repeat reassessments: • Every 15 minutes for a stable patient • Every 5 minutes for an unstable patient

  44. Performing Reassessment • The primary assessment of responsiveness, breathing and circulation • Vital signs • The chief complaint

  45. Importance of Reassessment • Check that your interventions are effective • Perform additional treatments as needed

  46. Compare Reassessment Results to Baseline Status • Level of responsiveness • Airway maintenance • Adequacy of breathing (rate, depth, effort) • Adequacy of circulation (carotid or radial pulse; skin color, temperature and moisture) • Chief complaint (pain remains the same, getting worse or getting better) • Presence of new or previously undisclosed symptoms

  47. Hand-Off Report • Give EMS hand-off report with detailed information about the patient’s: • Age and gender • Chief complaint • Responsiveness • Airway and breathing status • Circulation status

  48. Hand-Off Report (continued) • Also include: • Vital signs and physical examination findings • Results of SAMPLE history • Interventions provided and the patient’s response to them • You may also complete a written report containing the same information

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