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© 2011 National Safety Council 11-1
SECONDARY ASSESSMENTLESSON 11
© 2011 National Safety Council 11-2
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
© 2011 National Safety Council 11-3
Patient History
© 2011 National Safety Council 11-4
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
© 2011 National Safety Council 11-5
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
© 2011 National Safety Council 11-6
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
© 2011 National Safety Council 11-7
SAMPLE
S = Signs and symptoms
A = Allergies
M = Medications
P = Pertinent past history
L = Last food or drink
E = Events
© 2011 National Safety Council 11-8
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
© 2011 National Safety Council 11-9
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
© 2011 National Safety Council 11-10
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
© 2011 National Safety Council 11-11
Vital Signs
• Some EMR check 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
© 2011 National Safety Council 11-12
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
© 2011 National Safety Council 11-13
Normal Vital Signs
Patient Normal Respiratory Rate at Rest
Normal Pulse Rate at Rest
Normal Blood Pressure (systolic/diastolic)
Infant 30-40 100-160 70-100 / 56-70
Child 20-30 70-130 70-120 / 50-80
Adult 12-20 60-100 118-140 / 60-90
© 2011 National Safety Council 11-14
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)
© 2011 National Safety Council 11-15
• 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
Assessing Respiration (continued)
© 2011 National Safety Council 11-16
Characteristics of Respiratory Distress
• Gasping or wheezing
• Very fast or slow respiratory rate
• Very shallow or very deep breathing
• Shortness of breath, difficulty speaking
© 2011 National Safety Council 11-17
Assessing Pulse
1. Have a responsive patient sit or lie down
2. 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
3. Count the beats for 30 seconds and multiply by 2
4. Note strength of pulse (strong or weak)
5. Note rhythm of pulse (regular or irregular)
© 2011 National Safety Council 11-18
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
© 2011 National Safety Council 11-19
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
© 2011 National Safety Council 11-20
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
© 2011 National Safety Council 11-21
• Assess size of patient’s pupils
• Assess the pupils for equality
• Assess reactivity to light
Assessing Pupils
© 2011 National Safety Council 11-22
Assessing Pupils (continued)
Pupil characteristics that may indicate a problem:
• Dilated or constricted pupils
• Unequal pupils
• Non-reactive pupils
© 2011 National Safety Council 11-23
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
© 2011 National Safety Council 11-24
• 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
Blood Pressure (continued)
© 2011 National Safety Council 11-25
Skill: Measuring Blood Pressure by Auscultation
© 2011 National Safety Council 11-26
© 2011 National Safety Council 11-27
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
© 2011 National Safety Council 11-28
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”)
© 2011 National Safety Council 11-29
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
© 2011 National Safety Council 11-30
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
© 2011 National Safety Council 11-31
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
© 2011 National Safety Council 11-32
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
© 2011 National Safety Council 11-33
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
© 2011 National Safety Council 11-34
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
© 2011 National Safety Council 11-35
DOTS for Trauma Patients
D = Deformities
O = Open injuries
T = Tenderness (pain)
S = Swelling
© 2011 National Safety Council 11-36
DCAP-BTLS Memory Aid
D = Deformities
C = Contusions
A = Abrasions
P = Punctures/Penetrations
B = Burns
T = Tenderness
L = Lacerations
S = Swelling
© 2011 National Safety Council 11-37
Check Head and Neck
• Skull
• Eyes
• Ears
• Nose
• Breathing
• Mouth
• Neck
© 2011 National Safety Council 11-38
Check Chest
• Deformity?
• Wounds?
• Tenderness?
• Bleeding?
• Use of accessory muscles?
• Equal chest rise?
© 2011 National Safety Council 11-39
Check Abdomen
• Rigidity?
• Pain?
• Bleeding?
© 2011 National Safety Council 11-40
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
© 2011 National Safety Council 11-41
Check Hips and Pelvis
• Tenderness?
• Instability?
• Incontinence?
• Priapism?
© 2011 National Safety Council 11-42
Check Lower Extremities
• Bleeding? Asymmetry? Deformity? Pain?
• Normal movement, sensation, temperature?
• Circulation?
© 2011 National Safety Council 11-43
Check Upper Extremities
• Bleeding? Deformity? Pain?
• Medial alert identification?
• Normal movement, sensation, temperature?
• Circulation?
© 2011 National Safety Council 11-44
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 and physical examination
• Repeat reassessments:
- Every 15 minutes for a stable patient
- Every 5 minutes for an unstable patient
© 2011 National Safety Council 11-45
Performing Reassessment
• The primary assessment of responsiveness, breathing and circulation
• Vital signs
• The chief complaint
© 2011 National Safety Council 11-46
Importance of Reassessment
• Check that your interventions are effective
• Perform additional treatments as needed
© 2011 National Safety Council 11-47
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
© 2011 National Safety Council 11-48
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
© 2011 National Safety Council 11-49
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