Secondary Assessment questions Flashcards
Name the body systems in the secondary survey
- Neurological
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Skin
- Neurovascular
Neurological assessment suggestions
- Speach clear, slurred or difficult
- Pupils reactivity (pearl)
- Nystagmus (stroke, trauma, alcohol or drug use)
- Trouble swallowing
- Drool
- Dizziness
- Headache
- confusion
Cardiovascular assessment suggestions
- Chest Pain or discomfort
- Palpitations
- Irregular pulses, (weak thready not unilateral)
- Absent pulse
- Cap refill central vs peripheral
- Oedema
Respiratory assessment suggestions
- Breath sounds
- Breathing pattern
- ER&F
- Cough (dry, wet, productive)
- Sputum color
- Audible wheeze or stridor
- ## WOB
Gastrointestinal assessment suggestions
- Abdomen soft and non-tender
- Bowel actions, normal for pt in freq, texture, colour, size and odour
- Appetite and intake
- Weight loss
- Abdo pain
- Vomiting
Genitourinary assessment suggestions
- Urinary frequency
- colour and odour of Urine
- Pain associated with urination
- Haematuria
Musculoskeletal assessment suggestions
- Extremity movement equal
- Muscle weakness
- Altered gait
- Stiff neck
Neurovascular assessment suggestions
- Colour (pale, mottled, Cyanosis)
- Temp (cool clammy warm)
- Capillary refill
- Distal pulses
- Sensation (reduced, tingly, absent)
- Movement (normal, involuntary
- Pain (pain out of proportion for injury)
Focused Assessment suggestions
- SIRS
- RASH
- AEIOUTIPS
- MASS & ACTFAST
- 5 HEDS
SIRS = ?
Systemic Inflammatory Response Syndrome
- Temp <36 or >38
- HR over 90
- RR over 20
- CO2 <32mmhg
AEIOUTIPS
Stroke differentials
A - Alcohol
E - Epilepsy
I - Insulin
O - Overdose
U - Underdose
T - Trauma Head
I - Infection
P - Pain/psychosis
S - Stroke
MASS
- Face droop (ask patient to show their teeth
- Speech ask patient to repeat “you cant teach an old dog new tricks” listen for slurring
- Hand grip (ask patient to squeeze finger noting bilateral strength
Stroke Mimics
- Hypo/hyperglycemia
- Seizures
- Migraine
- Sepsis
- Intoxication
- Brain tumor
- Syncope
- Inner ear disorder
- Subdural Haematoma
- Electrolyte disturbances
- MS
ACT FAST
Face. Arms. Speech. Time
Onset of deficits in last 24 hours, previously independent and rule out stroke mimics
Ask patient to hold arms out at 45 degrees for 10 seconds
If right arm falls
- assess speech if note just slurring but gibberish
- assess commend can they make a fist (rt side) or open mouth.
If LEFT arm drops
- observe both eyes (are they deviated away from weak side)
- tap shoulder on weak side and call name (fails to notice tapping.
RASH
In the setting of anaphylaxis
2 or more of RASH +/- confirmed exposure to antigen < 30 minutes up to 4 hours
- Respiratory distress
- Abdominal symptoms
- Skin rash
- Hypotension
or isolated hypotension SBP<90 with exposure to known allergen
or isolated respiratory symptoms with known exposure to antigen
