Chapter 14 Secondary Assessment

Question 1

Sign

Answer 1

something regarding the patients condition that you can see

Question 2

symptom

Answer 2

something regarding the patients condition that the Patient tells you

Question 3

Reassessment

Answer 3

Procedure for detecting changes in a patients condition. involves 4 steps

• repeat primary assessment (ABC’s)
• repeating recording of vital signs
• repeat physical exam
• checking interventions

Question 4

best to begin with these kinds of questions

Answer 4

open ended questions

Question 5

Open ended Questions

Answer 5

Questions to which a patient CANT just give a yes or no too

Question 6

Close ended Questions

Answer 6

Questions to which a patient CAN just give a yes or no to

Question 7

when patient doesn’t look good they should be asked with these kinds of questions

Answer 7

Close ended questions

Question 8

SAMPLE

Answer 8

• Signs and symptoms - Whats Wrong?
• Allergies
• Medication
• Past pertinent history
• Last oral intake
• Events leading to injury

Question 9

OPQRST

Answer 9

• Onset - What were you doing?
• Provocation - Does anything Trigger pain/ make it feel better?
• Quality - How would you describe it?
• Radiate - Where is pain-point at it-does it shoot or spread?
• Severity - on a scale of 1-10?
• Time - when did the pain happen?

Question 10

Three techniques to may use in physical examination

Answer 10

• Observe
• Auscultate
• Palpate

Question 11

Respiratory assessment - History

Answer 11

Dyspnea on exertion
- difficulty breathing after exertion

Weight gain
- does patient have recent rapid weight gain; signs of edema (fluid buildup - heart failure)

Orthopnea
- Difficulty breathing when laying down? occurs in several respiratory conditions including Heart Failure

Does patient have a cough? has been productive? whats been coughed up?

Any respiratory conditions (flu, bronchitis, cold, etc)?
Does patient have chronic illness (COPD, asthma, emphysema)?

Question 12

Respiratory Physical Exam

Answer 12

Mental Status
- AMS may be caused by hypoxia

Level of respiratory distress
- work of breathing, accessory muscle use

Observe chest wall motion
- equal rise/fall, alterations indicate trauma or pneumothorax

Auscultate Lung Sounds
- Listen for abnormalities

Pulse oximetry for SpO2 reading

Observe Edema

• Pedal edema (swelling of feet)
• Pulmonary edema (Gurgling in lungs)
• JVD

Fever

Question 13

Cardiovascular: History

Answer 13

Obtain history of Existing Cardiac Condition and medications

Determine if signs/symptoms resemble previous episode

Description of any chest pain

Specific characteristics of pain

Question 14

Cardiovascular: Physical Examination

Answer 14

Look for signs that the condition may be severe
- Skin color, temperature, condition, AMS

Obtain a pulse
- Alert for irregular or thready(weak) beats

Obtain BP
- to indicate High/Low BP, taking in both arms; if significant difference may indicate aortic aneurysm

Note Pulse Pressure
- narrowing may indicate shock

Look for JVD (Jugular vein Distention)
- may indicate Heart Failure

Palpate chest
- may indicate trauma

Observe posture and breathing

Question 15

Nervous system: history

Answer 15

Determine AMS
- AOx4

Determine the patients normal state of mental functioning

Obtain history of neurologic conditions
- may have had previous stroke or TIA (transient ischemic attacks)

Note the the patients speech
- may indicate brain dysfunction

Question 16

Nervous system: Examination

Answer 16

Perform a stroke Scale
- Smile, Arm drift, speech

Check peripheral sensation and movement
- check extremities for movement (wiggle finger, move toes) unequal or absent movement may indicate spine damage

Gently Palpate the spine for tenderness or deformities

Check extremity strength
- have patient squeeze your finger with hand or raise foot

Check Pupils
- PEARL

Question 17

Endocrine system: History

Answer 17

History of endocrine conditions?

Any medication?

Last oral intake?

Has patient exerted himself at an unusual level?

Is patient currently sick?

Has patient been taking his Blood Glucose regularly?

Does patient have Insulin Pump

Question 18

Endocrine system: Physical Examination

Answer 18

Evaluate patients mental status
- hypoglycemia with AMS

Patients skin color, temp
- may occur in hypoglycemia

Obtain Blood Glucose Levels

Look for an insulin pump

Question 19

Gastrointestinal System: History

Answer 19

Oral intake?

Any pain?

History of GI issues?

Has patient vomited? how much? how frequent? How did it look like?

Bowel Movement questions

Question 20

Gastrointestinal System: Physical examination

Answer 20

Observe Patients position
- Is patient in fetal position, guarding abdomen

Assess abdomen by palpitation of abdominal quarters

inspect Vomit, feces

Question 21

Immune system: history

Answer 21

Any Allergies?

Has Patient been exposed to anything their allergic to?

What are typical reactions when patient has a reaction?

Does patient feel tightness in chest/throat, difficulty breathing, swelling around face

Does patient have medication for allergic reaction

Question 22

Immune system: Physical Examination

Answer 22

Inspect point of contact with allergen

Inspect Patients skin
- Hives

Inspect Patients face for swelling

Listen to lungs for abnormal sounds/ adequate breathing

Question 23

Musculoskeletal System: History

Answer 23

Did patient have any prior injuries?

Do They take blood thinning medication?

Use history to determine if medical problem cause traumatic injury

Question 24

Musculoskeletal System: Physical exam

Answer 24

Inspect for signs of Musculoskeletal injury

Palpate area in which you suspect injury

Compare opposite sides of patient : not asymmetry

Be alert for crepitation (the feeling of one ends rubbing together)

Head to toe Exam palpate major body areas and extremities