Chapter 14 Secondary Assessment Flashcards
Sign
something regarding the patients condition that you can see
symptom
something regarding the patients condition that the Patient tells you
Reassessment
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
best to begin with these kinds of questions
open ended questions
Open ended Questions
Questions to which a patient CANT just give a yes or no too
Close ended Questions
Questions to which a patient CAN just give a yes or no to
when patient doesn’t look good they should be asked with these kinds of questions
Close ended questions
SAMPLE
- Signs and symptoms - Whats Wrong?
- Allergies
- Medication
- Past pertinent history
- Last oral intake
- Events leading to injury
OPQRST
- 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?
Three techniques to may use in physical examination
- Observe
- Auscultate
- Palpate
Respiratory assessment - History
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)?
Respiratory Physical Exam
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
Cardiovascular: History
Obtain history of Existing Cardiac Condition and medications
Determine if signs/symptoms resemble previous episode
Description of any chest pain
Specific characteristics of pain
Cardiovascular: Physical Examination
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
Nervous system: history
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
Nervous system: Examination
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
Endocrine system: History
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
Endocrine system: Physical Examination
Evaluate patients mental status
- hypoglycemia with AMS
Patients skin color, temp
- may occur in hypoglycemia
Obtain Blood Glucose Levels
Look for an insulin pump
Gastrointestinal System: History
Oral intake?
Any pain?
History of GI issues?
Has patient vomited? how much? how frequent? How did it look like?
Bowel Movement questions
Gastrointestinal System: Physical examination
Observe Patients position
- Is patient in fetal position, guarding abdomen
Assess abdomen by palpitation of abdominal quarters
inspect Vomit, feces
Immune system: history
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
Immune system: Physical Examination
Inspect point of contact with allergen
Inspect Patients skin
- Hives
Inspect Patients face for swelling
Listen to lungs for abnormal sounds/ adequate breathing
Musculoskeletal System: History
Did patient have any prior injuries?
Do They take blood thinning medication?
Use history to determine if medical problem cause traumatic injury
Musculoskeletal System: Physical exam
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
