Ch. 5b Secondary Assessment Flashcards
what is in the secondary assessment
SAMPLE
OPQRST
head to toe
vitals (within 5 min)
What are you doing when assessing the head
Observe for discharge
Assess pupil size
observe for bruising behing the ears
reassess airway
look for blood or clear fluid coming from the ears, nose or mouth
what do raccoon eyes indicate
basal skull fx
what are you looking for when assessing the neck
airway
tracheal deviation
jugular vein distension/flatness
cervical trauma
what do you do if you suspect a pelvic fx
maintain manual stabilization until pelvic binder is attached
timing of vitals
within 3-5 min after arrival
every 5 min
every 15 min if stable
what are the 4 vital signs
pulse
vent rate
BP
Pulse ox
normal pulse values
adult: 60-80bpm
child: 80-100bpm
toddler: 100-120
Athlete: 50-60
interpretation of vent rate: rapid/shallow
shock
bleeding
heat exhaustion
interpretation of vent rate: rapid/deep
cheyne-stokes, neurologic, metabolic
interpretation vent rate: prolonged expiratiory
lower airway obstruction, asthma
interpretation vent rate: prolonged inspiratory
upper airway obstruction
interpretation vent rate: deep gasping laboured
obstructive, chest injury
interpretation vent rate: absent
obstructive
respiratory arrest
many cases
BP systolic range
female 20-50yo: 90mmHg + age
male 20-50 yo: 100mmHg + age
BP diastolic range
around 80 mmHg
normal difference btw sys and dias
50 mmHg
If no cuff available for BP
Radial: at least 80 sys
Femoral: at least 70 sys
carotid: at least 60 sys
SPO2 normal range
95-100%
problematic saturation
< 90%
do not start O2 therapy above
93%
Stop O2 therapy no higher than
96%
no supplemental O2 in what case
acute stroke/MI with sPO2 btw 93-100%
Normal body temp
37ºC /98.6ºF
oral and rectal temps measure
3 min
why rectal temp
more accurate in thermo-regulatory emergencies
contraindications of rectal temp
cardiac issues (vagal nerve stim)
hemorroids
recent rectal surgery
diarrhea
skin colour interpretation :red
burn
fever
allergic rx
heat stroke
hypertensive
skin colour interpretation: blue
cyanosis
hypoxemia
vasoconstriction
cold
shock
skin colour interpretation: yellow
jaundice
skin colour interpretation: mottled
CV embarassment
What can affect PERRLA
concussion
whats is the GSC of a concussion
14
can indicate life-threatening TBI
at what GSC do you intubate
8
reaction to pain: abnormal flexion/extension
decorticate
decerebrate
vitals signs
Vitals interpretation: physiological shock
dec BP
inc PR
inc VR
Vitals interpretation: neurogenic shock
dec BP
no change in PR
vitals interpretation : cushings signs
inc BP
dec PR
inc TEMP
inc intracranial pressure