secondary assessment Flashcards
what does bruising behind the ear can indicate
basal skull fracture
what is battle sign
raccoon eye: basal skull fracture
what do you look for when assessing the head
Observe for discharge
Assess pupil size
❑ Observe for bruising behind the ears
❑ Reassess airway
❑ Look for blood or clear fluid coming from ears, nose or mouth
what do you asses in the neck
airway, tracheal deviation,
jugular vein distension/flatness, cervical trauma…
what do you asses in the chest and back
Assess for abnormalities
❑ Look and listen for more subtle signs of breathing difficulties
what do you assess in the abdomen
Gently feel the top of the abdomen
Palpate for:
-Rigidity -Tenderness
what do you asses in the pelvis
Observe for incontinence and/or blood
❑ Place hands on both sides of the pelvis: in-
flare, alternate rotation.
Do not “open book” a potential pelvic fracture.
the arm are done when during secondary assessment
at the end
vital are done every _ min and if stable
5
15
average pulse in adult, child, toddler, athlete
adult 60-80 bpm
child 80-100 bpm toddler 100-120 bpm athlete 50-60 bpm
interpretation of pulse if rapid/weak
shock, bleeding, diabetic coma
interpretation of pulse if rapid/strong
fright, apprehension, heat, CVA
interpretation of pulse if slow/strong
stroke, skull fracture, etc.
name some caractéristique of the ventilatory rate
normal, shallow, deep, depressed, arrest, labored, gasping, noisy, agonal, etc.
interpretation of rapid/shallow ventillatory
shock, bleeding, heat exhaustion
interpretation of rapid/deep ventillatory
cheyne-stokes, neurologic, metabolic…
interpretation of prolonged expiration in ventillatory rate
lower airway obstruction, asthma…
interpretation of prolonged inspiration during ventillatory rate
upper airway obstruction…
interpretation of deep gasping laboured during ventillatory rate
obstructive, chest injury
interpretation of absent ventillatory rate
obstructive, respiratory arrest, many cases…
interprétation of bright frothy coughed up blood
lung injury
systolic BP female and male
female range 90mm Hg + age (20-50 age) male range 100mm Hg + age (20-50 age)
diastolic BP
around 80mm hg
if no cuff available listen for radial, femoral, carotid pulse and it need to be at least at
If radial pulse at least 80mm Hg sys
If femoral pulse, at least 70 mm Hg sys
If carotid pulse, at least 60 mm Hg sy
when does SP02 start to become problematic
<90%
can we start O2 therapy at or above 93% SPo2 and when do we stop
no and at 96%
what does cool/clammy skin indicate
shock, bleeding, heat exhaustion…
what does hot/moist skin indicate
reaction to increased temperature, exercise
what does hot/dry skin indicate
heat stroke, high fever
contraindication of rectal temperature
cardiac issue (vagus nerve stimulation)
-hemorrhoids
-recent rectal surgery -diarrhea
what is a sims position
position for rectal temperature, side line with top knee flex
how to apply thermal temp
Thermometer, cover, gauze, lubricant, watch
* Shake thermometer down, apply cover, lubricate
* Lift upper buttock, expose, have athlete breath in then out (insert) * Insert 1-2”,release buttock,
* Hold thermometer 3 min, ensure safe position
* Lift buttock, tell athlete thermometer removed on exhalation
* Wipe thermometer with gauze, read, clean
interpretation of blood under skin colour
red
blue
yellow
mottled
ed- burn, fever, allergic rx, heat stroke, hypertensive… blue- cyanosis, hypoxemia, vasoconstriction, cold, shock… yellow- jaundice
mottled- cardio-vascular embarassment
how many mm of pupil difference is significant
> 1mm
GCS + abnormal pupil become abnormal when
GCS < 14 in combination with abnormal pupil
exam can indicate presence of life-threatening TBI
