NU2ICU V3 logoASSESSMENT – SECONDARY

Something in your primary assessment has triggered you into believing further immediate intervention is required.  This is where you collect the necessary information to direct your interventions and actions

The secondary survey consists of;

How well are they? = Vital signs

What are their injuries / what is their condition?  = Patient examination

What is their past medical history?  = Short history summary

What is our patient care plan?  = Put it all together – Nursing interventions and initial recommendations

 

VITAL SIGNS: How well are they doing?

Respiratory Rate and Effort and SaO2:

Shows us how well the Respiratory System, the airway and lungs are doing supplying the brain with O2.

  • LOOK –  Do they look like they are having difficulty breathing, fast or slow, what’s the SaO2, do they need to sit up?
  • LISTEN –  Are they complaining of shortness of breath or difficulty breathing?
  • FEEL –  Is the chest moving properly with breathing?

 

Heart Rate and Blood Pressure:

Tells us how well the Cardiovascular System, the heart and blood vessels, are doing

  • LOOK     –  Do they look shocked, pale or grey, agitated or drowzy?
  • LISTEN –  What is there heart rate
  • FEEL      –  Take a blood pressure

 

Level of consciousness / sensation and strength:  tells us how well the Central Nervous System – the brain and spinal cord, are doing

Level of Consciousness is determined using the Glasgow Coma Scale (GCS):

Level of response to trying to wake them, ability to speak, environmental stimulus

Are their eyes open spontaneously?

Speak to them, do they react to hearing their name?

Response to painful stimuli?   Use a pinch to the trapezius muscle (not a sternal rub or nail beds)

Is there any response to verbal or painful stimuli?

 

Pull back those sheets and observe – is there blood in the bed from wounds, bowel or bladder?

Skin colour, temperature, and moisture:

baseline colour, of course, varies by individual and race

  • Look  –  What is their skin colour, pale, ashen, cyanotic?
  • Listen –  Are they complaining about feeling hot or cold?
  • Feel  –  Is their skin dry, moist, clammy, hot, or cold?

 

You can try to remember the mnemonic  A.M.P.L.E.

A = allergies

M = medications

P = past medical history

L = last meal

E = events leading up to this issue

If they are are awake and able now is the time to get that history and A.M.P.L.E.      Has “this” happened before,  if so what was the treatment last time?   Ask about things related to what you see like unstable diabetes, distance able to walk unaided, known lung diseases and other chronic illnesses.

When you put the picture of what concerned you, your collected vital signs and what the patients history is together then you must make a plan to either initiate already existing ordered medications or therapy or to seek medical or senior nursing review and based on the patients current state, you must decide the time frame you will accept for this to happen.   The important thing is you must act, make a plan and what your recommendations are and have the information you’ve gathered ready to pass on.

So we have learnt to follow up on our assessment and go back to have a second look at what wasn’t right.  Brilliant keep up the great work!

NU2ICU

 

REFERENCES

Clinical Examination : a systematic guide to physical diagnosis 6th Edition 2010 by Nicholas J. Talley, Simon O’Connor.

Oxford Handbook of Clinical Examination and Practical Skills, 1st Edition 2007 by James Thomas, Tanya Monaghan

 

More reading

GENERAL ASSESSMENT

PRIMARY ASSESSMENT

KNOWLEDGE ADJUNCTS

AUSCULTATION SKILLS

NORMAL VALUES

RRS / MET VALUES

ASSESSMENT PRACTICE TOOL