22.5b Secondary Assessment

secondary assessment

After you complete the primary assessment and correct any immediate life threats, conduct the ? while continuously monitoring the patient’s airway, breathing, and circulation.

onset of symptoms

The time when a patient or family members noted the ? is important information as is whether the acute event occurred suddenly or gradually.

allergens and heat

Identifying possible triggers such as ? also can help the patient avoid them in the future.

course of development

Additionally, the symptoms’ ? since onset helps direct diagnosis and treatment.

progressively worsening, recurrent, or continuous

Have the person’s symptoms been ?

cause

Associated symptoms—fever or chills, productive cough, chest pain, nausea or vomiting, or diaphoresis—further help to assess the ? of the patient’s problem.

voice

Does the patient or family think the patient’s ? sounds normal?

past medical history

The ? of a patient can put the present complaint into perspective and help to identify the risk factors for a variety of likely diagnoses.

past episodes

Determine whether the present episode is similar to any ? of shortness of breath, what medical evaluations have been done, and what they have found.

intubated

Has the patient ever been ? or admitted to the hospital for these complaints?

recent history

The ? leading to the onset of symptoms is also important.

mechanism of injury

If an injury is involved, evaluate the ?.

larynx

Remember that blunt trauma to the neck could have injured the ?.

ameliorates, exacerbates/aggravates

Anything that makes the patient’s condition better (?) or worse (?) is also significant.

ABCs

Your physical examination of a patient with respiratory problems should continue the evaluation of the ? begun during your primary assessment.

inspection, auscultation, and palpation

At this point, use the physical examination techniques of ? to evaluate the injury or illness in more detail and determine your plan of action.

inspecting

Begin the physical assessment by ? the patient.

breathing

Evaluate the adequacy of the ?.

trauma

Note any obvious signs of ?.

oxygenation status

Always remember to assess skin color as an indicator of ?.

sympathetic nervous system

Early in respiratory compromise, the ? is stimulated to help offset the lack of oxygen.

pale and diaphoretic

When this happens, the skin often appears ?.

respiratory distress

Cyanosis (bluish discoloration) is another sign of ?.

bright red

When oxygen binds with the hemoglobin, the blood appears ?.

blue

Deoxygenated hemoglobin, however, is ? and gives the skin a bluish tint.

without cyanosis

This is not a reliable indicator, however, because severe tissue hypoxia is possible ?.

late

In fact, cyanosis is considered a ? sign of respiratory compromise.

lips, fingernails, and skin

When it does appear, it usually affects the ?.

allergic reaction

A red skin rash, especially if accompanied by hives, can indicate an ?.

carbon monoxide poisoning

A cherry-red skin discoloration may, on rare occasions, be associated with ?, as can bullae (large blisters).

COPD or asthma exacerbation

Tripod positioning (seated, leaning forward, with one arm forward to stabilize the body) can indicate ?.

congestive heart failure or asthma

Orthopnea (increased difficulty breathing while lying down) can indicate ?.

dyspnea

Next, inspecting for ?—an abnormality of breathing rate, pattern, or effort—is essential.

hypoxia

Dyspnea can cause or be caused by ?.

anoxia

Prolonged dyspnea without successful intervention can lead to ? (the absence or near absence of oxygen).

premorbid

Without intervention, anoxia is a ? (occurring just before death) event because the brain can survive only 4 to 6 minutes in this state.

patent airway

Remember that all interventions are useless if you do not establish a ?.

Coughing

? is a forceful exhalation of a large volume of air from the lungs performs a protective function in expelling foreign material from the lungs.

Sneezing

? is a sudden, forceful exhalation from the nose is usually caused by nasal irritation.

Hiccups

? are a sudden inspiration caused by spasmodic contraction of the diaphragm with spastic closure of the glottis which serves no known physiologic purpose.

acute myocardial infarctions

Hiccups have occasionally been associated with ? on the inferior (diaphragmatic) surface of the heart.

Sighing

? is a low, deep, involuntary inspiration followed by a prolonged expiration that hyperinflates the lungs and reexpands atelectatic alveoli.

once a minute

Sighing normally occurs about ?.

grunting

? is a forceful expiration that occurs against a partially closed epiglottis, usually indicating respiratory distress.

respiratory rate

Note any decrease or increase in the ?, one of the earliest indicators of respiratory distress.

accessory respiratory muscles

Also look for use of the ?—intercostal, suprasternal, supraclavicular, and subcostal retractions—and the abdominal muscles to assist breathing.

increased respiratory effort

Use of accessory and abdominal muscles indicates ? secondary to respiratory distress.

nasal flaring and grunting

In infants and children, ? indicate respiratory distress.

purse their lips

COPD patients having difficulty breathing ? during exhalation.

blood pressure

Monitor the patient’s ?, including any differences noted during expiration versus inspiration.

increased pressure within the thoracic cavity

Patients with severe COPD may sustain a drop in blood pressure during inspiration due to ? that impairs the ability of the ventricles to fill.

decreased blood pressure

Thus, decreased ventricular filling leads to ?.

pulsus paradoxus

A drop in blood pressure of more than 10 torr is termed ? and can indicate severe obstructive lung disease.

abnormal

Determine whether the pattern of respirations is ?—deep or shallow in combination with a fast or slow rate.

Kussmaul's respirations

? is a deep, slow or rapid, gasping breathing commonly found in diabetic ketoacidosis.

Cheye-Stokes respirations

? are progressively deeper, faster breathing alternating gradually with shallow, slower breathing indicating brainstem injury.

Biot's respirations

? is an irregular pattern of rate and depth with sudden, periodic episodes of apnea indicating increased intracranial pressure.

Central neurogenic hyperventilation

? is deep, rapid respirations indicating increased intracranial pressure.

Agonal respirations

? is shallow, slow, or infrequent breathing indicating brain anoxia.

altered mentation

Finally, ? can be key in determining whether breathing is adequate or if significant hypoxia may be present.

baseline mental status

You must determine the patient’s usual ? before you can assess for abnormal mentation.

adequate air movement

Following inspection, listen at the mouth and nose for ?.

auscultate

Then listen to the chest with a stethoscope (?).

six locations

When the patient’s condition permits, you can monitor ? on the posterior chest, three right and three left.

posterior surface

The ? is preferable because heart sounds do not interfere with auscultation at this location.

anterior and lateral positions

However because patients are usually supine during airway management, the ? usually prove more accessible.

equal bilaterally

Breath sounds should be ?.

partial obstruction of the upper airway

Snoring results from ? by the tongue.

accumulation of blood, vomitus, or other secretions

Gurgling results from the ? in the upper airway.

stridor

? is a harsh, high-pitched sound heard on inhalation; associated with laryngeal edema or constriction at the glottic opening.

wheezing

? is a musical, squeaking, or whistling sound heard in inspiration and/or expiration; associated with bronchiolar constriction.

Quiet lung sounds

? are diminished or absent breath sounds; an ominous finding and indicative of a serious problem with the airway, breathing, or both.

Crackles (rales)

? is a fine, bubbling sound heard on inspiration; associated with fluid in the smaller bronchioles.

Rhonchi

? is a coarse, rattling noise heard on inspiration; associated with inflammation, mucus, and fluid in the bronchioles.

air movement into the epigastrium

When you assess the effectiveness of ventilatory support or the correct placement of an airway adjunct, remember that ? can sometimes mimic breath sounds.

air movement

Thus, listening to the chest should be only one of several means that you use to assess ?.

epigastrium

Another method of checking correct placement of an airway adjunct is to auscultate over the ?; it should be silent during ventilation.

gastric distention

When you provide ventilatory support, watch for signs of ?.

improper placement of airway adjuncts

Gastric sounds suggest inadequate hyperextension of the neck, undue pressure generated by the ventilatory device, or ?

palpate

Finally, ?.

mouth and nose

Using the back of your hand or your cheek, first feel for air movement at the ?.

tube’s adapter

If an endotracheal tube is in place, you can check for air movement at the ?.

rise and fall

Next, palpate the chest for ?

chest wall

In addition, palpate the ? for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema.

compliance

When ventilating with a bag-valve device, gauge airflow into the lungs by noting ?, which refers to the stiffness or flexibility of the lung tissue.

minimal resistance

When compliance is good, airflow meets ?.

more difficult to achieve

When compliance is poor, ventilation is ?.

tension pneumothorax

Compliance is often poor in diseased lungs and in patients suffering from chest wall injuries or ?.

causes

If a patient shows poor compliance during ventilatory support, look for potential ?.

Upper airway obstruction

?, which cause difficulty with mechanical ventilation, can mimic poor compliance.

a new problem

If ventilating the patient is initially easy but then becomes progressively more difficult, repeat the primary assessment and look for the development of ?, possibly related to the mechanical airway maneuvers.

pulse rate

? abnormalities can also suggest respiratory compromise.

tachycardia

? (an abnormally fast pulse) usually accompanies hypoxemia in an adult.

bradycardia

? (an abnormally slow pulse) suggests anoxia with imminent cardiac arrest.