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.
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.
3
Q
components of primary assessment
A
Danger
Response
Send for help
Airway and c-spine
Breathing
Circulation
Disability
Exposure and environment
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.
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.
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.
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.
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
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
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
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:
12
Q
components of secondary assessment
A
- health history interview
- physical exam
- vital signs assessment
13
Q
health history interview
A
- Biographical data
- Reason for seeking care
- Perception of present state of health
- Past health and medical history
- Family history
- General overall health and wellbeing
- Health and lifestyle management
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
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.