Chapter 14: The Secondary Assessment Flashcards
Secondary Assessment
- where you find out what is wrong with the pt
- a series of examinations, both hands on and through pt history
- performed after the scene size-up and the primary assessment
Medical pt
a pt w/ one or more medical diseases or conditions
Trauma pt
a pt suffering from one or more physical injuries
Components of the secondary assessment
physical examination, patient history, vital signs
Physical examination of the S.A.
- use your sense to exam the pt
- you may feel for injuries, listen for abnormal breathing sounds, and look for swelling
Patient history of the S.A.
- obtained by asking important questions that will provide you with vital info about your pt’s current condition or complaint
- you find out history of the present illness (HPI) and the past medical history (PMH)
History of the Present Illness (HPI)
info gathered regarding the symptoms and nature of the pt’s current concern
Past Medical History (PMH)
info. gathered regarding the pt’s health problems in the past
Vital signs of the S.A.
- you will take vital signs such as pulse, respirations, blood pressure, and pulse ox.
- assess the skin and pupils
When to perform components of the S.A. in medical pts
- history first b/c history provides the most relevant info.
- then perform physical exam based on what you find in the history
When to perform components of the S.A. in trauma pts
- perform the hands on exam first–it provides the most info (you can ask initially if the pt hurts anywhere)
- in some pts you will do a head to toe exam, in others with minor injuries, you might just palpate one area
When to perform components of the S.A. in unresponsive pts
- get info from family and bystanders when you can
- physical exam will also be a primary source of info
sign
something regarding the pt’s conditions that YOU can see
symptom
something regarding the pt’s condition that the PT tells you
When to perform components of the S.A. in seriously ill or injured pts
- a serious trauma pt will get a primary assessment and a very quick secondary assessment to check for major injuries before transport.
- same goes for medical pts; they must be transport promptly to the hospital for lifesaving interventions
Reassessment
- a procedure for detecting changes in a pt’s condition
- involves 4 steps:
1. repeating the primary assessment
2. repeating and recording vital signs
3. repeating the physical exa,
4. checking interventions
Open-ended question
a question requiring more than just a yes or no
closed-ended question
a question requiring only a yes or no answer
SAMPLE
- a memory aid in which the letters stand for elements of the past medical history
S in SAMPLE
- S = signs and symptoms
- What is wrong?
A in SAMPLE
- A = allergies
- Are you allergic to medications or foods, or do you have environmental allergies?
M in SAMPLE
- M = medications
- What meds are you currently taking or are you supposed to be taking?
P in SAMPLE
P = pertinent past history
Have you been having any medical problems?
Have you had any recent surgeries or injuries?
Have you been seeing a doctor?
L in SAMPLE
L = last oral intake
When did you last eat or drink?
What did you eat or drink?
E in SAMPLE
E = events leading to the injury or illness
what sequence of events led up to today’s problem?
OPQRST
a memory aid in which the letters stand for questions asked to get a description of the present illness
O in OPQRST
Onset
What were you doing when the pain began?
P in OPQRST
Provocation
Does anything seem to trigger the pain? Does anything make it feel better?
Q in OPQRST
Quality
Can you describe the pain?
R in OPQRST
Region, relief
Where is the pain? Will you please point toward it? Does it seem to shoot or spread anywhere?
S in OPQRST
Severity
How bad is the pain on a scale of 1-10 with 10 being the worst pain you’ve ever felt.
T in OPQRST
Time
When did the pain start? Has it changed at all since it started?
Physical Exam Techniques
Observe, auscultate, palpate
Observation
looking at the pt for an overall sense of his condition as well as evaluating their chief complaint
Auscultation
listening for abnormal signs of an abnormal condition; mostly done with a stethoscope
Body systems exam: respiratory
- work of breathing and position
- pedal and sacral edema
- lung sounds
- pulse ox
- respiratory specific history
- dyspnea on exertion
- orthopnea
- weight gain
Body systems exam: cardiovascular
- check pulse (presence/rate/regularity)
- skin color/temp/condition
- blood pressure
- orthostatic blood pressure changes
- JVD
- many components of the respiratory exam also applies to the cardiovascular exam
Body systems exam: neurologic
- cincinnati prehospital scale (or other approved scale)
- pupils (equality, size, reactivity)
- monitoring mental status changes over time
Body systems exam: endocrine
- blood glucose monitoring
- skin (color/temp/condition)
- breath odors
- excessive hunger, thirst, or urination
- pupils
- monitoring mental status changes over time
- diabetic specific history
- oral intake
- medication history/use
- recent illness
Body systems exam: GI/GU
- palpation of abdominal quadrants
- GI/GU specific history
- input/output amount and frequency
- question or observe for bright red or digested blood in vomit, stool, or urine
- menstrual history and pregnancy where appropriate
Jugular vein distention (JVD)
bulging of the neck veins
crepitation
the grating sound or feeling of broken bones rubbing together
rapid trauma assessment
a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury
stoma
a permanent surgical opening in the neck through which the pt breathes
tracheostomy
a surgical incision help open by a metal or plastic tibe
paradoxical
movement of a part of the chest in the opposite direction to the rest of the chest during respiration
distention
a condition of being stretched, inflated, or larger than normal
priapism
persistent erection of the penis that may result from spinal injury and some medical problems
detailed physical exam
- an assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury
- it differs from the rapid trauma assessment only in that it also includes examination of the face, ears, eyes, nose, and mouth during the examination of the head
trending
changes in a pt’s condition over time, such as slowing respirations or rising pulse rate, that may show improvement
diagnosis
a description or label for a pt’s condition that assists a clinician in further evaluation and treatment
differential diagnosis
a list of potential diagnoses compiled early in the assessment of the pt
How an EMT can learn to think like an experienced physician
- learn to love ambiguity
- understand the limitations of technology and people
- realize that no one strategy works for everything
- form a strong foundation of knowledge
- organize the date in your head
- change the way you think
- learn from others
- reflect on what you have learned
