WEEK 3 NURSING - PRIMARY, SECONDARY AND FOCUSED ASSESSMENT Flashcards

1
Q

purpose of primary assessment

A
  • A primary assessment is a systematic approach that
    includes all body systems.
  • Quickly identifies the deteriorating and critically ill patient and intervene rapidly
  • Main focus is to stabilise the patient before moving on to
    secondary and focused assessments that can assist in
    diagnosis and treatment.
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2
Q

what is a primary assessment

A
  • Rapid assessment used to identify life threatening conditions to allow for prompt management.
  • Performed shortly after the person is admitted to a
    healthcare service or when you first enter their room.
    -Enables care to be prioritised based on immediate patient requirements based on their current state of health.
  • Help recognise when more senior nursing and medical
    help is required.
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3
Q

components of primary assessment

A

Danger
Response
Send for help
Airway and c-spine
Breathing
Circulation
Disability
Exposure and environment

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4
Q

danger

A
  • Identify any dangers to patient and self or other healthcare professionals involved in the situation.
  • Dangers can include aggressive bystanders, blood
    and bodily fluids, sharps, spills on the floor.
  • Stop and remove the dangers if safe to do so before
    attempting to help the patient. Do not place yourself
    at danger.
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5
Q

response

A
  • Can you elicit any verbal or motor response?
  • Do this by asking the patient to open their eyes or touch and squeeze their shoulder.
  • Failure to respond is a clear indicator of serious illness.
  • Very little time should be spent on this. If there is no
    response from your patient you need to quickly move
    on to the next step.
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6
Q

send for help

A
  • If you cannot elicit a response OR there is danger call
    for help!
  • Press the emergency call button, shout for help or dial
    the hospital emergency number
  • Never leave an unconscious patient alone, always
    stay with them until help arrives.
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7
Q

airway and c-spine

A
  • Ensure airway is patent
  • Perform a head tilt and chin lift manoeuvre to open
    the airways.
  • Assess for airway compromise – consider using
    suction to remove any fluid or Magill’s forceps to
    remove solid material.
  • Think about potential spinal cord injury and manage
    as required
  • Use a jaw-thrust manoeuvre if you suspect a spinal
    injury.
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8
Q

breathing

A
  • Assess for effective respirations
  • Assess air entry to the lungs
  • Assess skin and mucous membrane colour
  • Check chest wall movement, expansion and
    symmetry
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9
Q

circulation

A
  • Check for signs of impending cardiovascular collapse
  • Assess central pulses
  • Assess pulse rate and quality
  • Assess skin colour and warmth
  • Assess capillary refill
  • Assess/manage internal and external haemorrhage
  • Auscultate to hear the S1 and S2 heart sounds
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10
Q

disability

A
  • Assessment of central nervous system function
  • AVPU (Alert, responsive to Verbal stimulus,
    responsive to Painful stimulus, Unconscious and
    unresponsive)
  • Check pupil response (PEARL) and consensual
    reaction. Pupils Equal And Reactive to Light
  • Limb assessment for strength and sensation
  • Ask about pain
  • Check for reversible causes of reduced consciousness:
    – Medications (i.e. opioids, benzodiazepines, hypnotics)
    – Blood glucose level
    – Haemorrhagic shock and hypotension
    – Overdose
    – Anaphylaxis
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11
Q

environment and exposure

A
  • Remove clothing to expose patient as required
  • Maintain body temperature during exposure
  • Assess for signs of injury, trauma or illness (i.e.
    anaphylaxis)
  • Assessment for clues to the cause of patient condition
  • Ensure emergency equipment is available at
    bedspace:
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12
Q

components of secondary assessment

A
  • health history interview
  • physical exam
  • vital signs assessment
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13
Q

health history interview

A
  1. Biographical data
  2. Reason for seeking care
  3. Perception of present state of health
  4. Past health and medical history
  5. Family history
  6. General overall health and wellbeing
  7. Health and lifestyle management
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14
Q

physical exam

A
  • Head-to-toe or systems assessment of body systems:
    – General survey
    – Head and neck
    – Neurological
    – Cardiovascular
    – Respiratory
    – Gastrointestinal
    – Genitourinary
    – Skin and extremities
    – Endocrine
    – Posterior
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15
Q

focused assessment

A
  • Thorough assessment of a particular clinical manifestation
    related to a particular body system.
  • Completed throughout each shift and at handover to
    review patient progress and detect deterioration.
  • Using the skills of inspection, auscultation, palpation and
    percussion.
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