Chapter 15 - Secondary Assessment

First step in Secondary Assessment

Physical Exam

Second step in Secondary Assessment

Pt History

Third step in Secondary Assessment

Vital Signs

A sign

something you can see; objective

A symptom

something the pt tells you; subjective

Pt assessment is a __ process

dynamic

Reassessment

A step within the patient assessment process that is performed at regular intervals to identify and treat changes in a patient's condition, A patient in unstable condition should be reassessed every 5 minutes, whereas a patient in stable condition should be reassessed every 15 minutes

In a conscious pt, obtain your SAMPLE early because

they can become unconscious

Rapid Physical Exam

• Similar to physical exam for trauma patient • Assess head, neck, chest, abdomen, pelvis, extremities, and posterior

Rapid Head-To-Toe Exam

Unresponsive trauma patient

Detailed physical assessment

The part of the assessment process meant to demote in depth exam of one or more body systems, used when more information is needed

DCAP-BTLS

deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, swelling

Deformities

abnormally formed parts of the body

Contusions

bruises

Abrasions

scrapes

Punctures

result from penetration by small sharp object

Burns

tissue damage and cell death caused by heat, electricity, UV radiation, or chemicals

Tenderness

pain felt on the release of pressure

Lacerations

a deep cut or tear in skin or flesh.

Swelling

a part of your body that has become bigger because of illness or injury

C-Collar

A neck brace that is put in place after a trauma and possible neck injury. It is removed after either exam or radiographic imaging has assured there is no c-spine injury.

Rapid Trauma Assessment

a rapid assessment of the head, neck, chest, abdomen, pelvis, extremities, and posterior of the body to detect signs and symptoms of injury

Significant fall for adult

>20 feet

Significant fall for pediatric

> 10 feet or 2-3 times their height

High risk auto crashes include

intrusion of >12 inches to occupant side or 18 inches to any locations; ejection; death in same vehicle; auto vs pedestrian; motorcycle crash at 20 mph

CSF

cerebrospinal fluid

Battle signs

Bruising behind the ears, indicative of a basilar skull fracture

pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall

cardiac tamponade

pressure on the heart caused by fluid in the pericardial space

Flail chest

fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment

paradoxical motion

movement of a part of the chest in the opposite direction to the rest of the chest during respiration

distention

the state or act of extending or being swollen out of shape

priaprism

persistent and painful erection, often due to trauma

detailed physical exam

An in-depth head-to-toe physical exam; takes more time than the rapid assessment and is only done when time and the patient's condition allow.