Secondary Assessment Notes

Secondary Assessment

  • Follows the primary assessment (DRSABCDE).
  • Performed as part of an initial patient assessment (admission, start of shift).
  • Aids in recognizing problems identified during the primary assessment or patient complaints.
  • Assists in establishing a diagnosis (though diagnosing is not within a nurse's responsibility).
  • Enables the identification of a treatment plan.

Components of Secondary Assessment

  • Health History
  • Vital Signs
  • Physical Examination

Health History

  • A more in-depth assessment compared to the primary assessment.
  • Focuses on the reason the patient is seeking healthcare.
  • Questions target key areas to guide patient care.
  • Can provide the diagnosis in 70% of patient presentations.

"SAMPLE" Mnemonic for Health History

  • Symptoms
    • Description: Patient's chief complaints.
    • Questions to Ask: "What's wrong?", "What brought you to the hospital?"
  • Allergies
    • Description: Identifying allergic reactions.
    • Questions to Ask: "Are you allergic to anything?", "What happens when you use something you're allergic to?"
  • Medications
    • Description: Prescribed, over-the-counter, and herbal medications.
    • Questions to Ask: "Are you taking any medications?", "What are you taking the medications for?", "When did you last take your medications?"
  • Past Medical History
    • Description: Previous state of health and illnesses.
    • Questions to Ask: "Have you had this problem before?", "Do you have other medical problems?"
  • Last Oral Intake
    • Description: Recent food and drink consumption.
    • Questions to Ask: "When did you last eat or drink anything?", "What was it that you last ate?"
  • Events
    • Description: Events leading up to the illness or injury.
    • Illness: "What led to this problem?"
    • Injury: "How did you get hurt?"
  • Important Note: Do not obtain a detailed history until life-threatening injuries have been addressed and therapy initiated.
  • The secondary survey is a head-to-toe assessment, evaluating progress and vital signs.

Vital Signs

  • A standard nursing assessment.
  • Performed at least once per shift.
  • Reassessed as needed based on patient condition.
  • Includes:
    • Respiratory Rate (RR)
    • Heart Rate (HR)
    • Blood Pressure (BP)
    • Temperature (Temp)
    • Pulse Oximetry (SpO2)

Physical Examination

  • Assessment should be tailored to the individual patient.
  • Systematic approach.
  • Head-to-toe assessment.
  • Includes anterior and posterior surfaces.

Techniques

  • Inspection
  • Palpation
  • Percussion
  • Auscultation

Nursing Assessment Components

  • Neuro
    • Mental status, Glasgow Coma Scale (GCS), Level of Consciousness (LOC), Pupils Equal, Round, Reactive to Light and Accommodation (PERRLA), Range of Motion (ROM).
  • Cardiovascular
    • Heart Rate (HR), Blood Pressure (BP), heart sounds, capillary refill.
  • Respiratory
    • Respiratory Rate (RR), Oxygen Saturation (SpO2), respiratory pattern, use of accessory muscles, nasal flaring, breath sounds.
  • Renal
    • Urine output, color, consistency, bladder distention, voiding method.
  • Gastrointestinal
    • Bowel sounds, peristalsis, palpation, diet, stool quantity, frequency, appearance.
  • Integumentary
    • Skin turgor, color, moisture, lesions, breakdown, bruising, dressings.

Primary vs. Secondary Assessment

CharacteristicPrimary AssessmentSecondary Assessment
DefinitionFirst examination and evaluation of a patient by a medical person.Second patient evaluation involving detailed history and physical exam.
StageFirstSecond (after triage and primary assessment)
TriageImportant stage during triage.Occurs after patient has been triaged and a primary assessment completed.
MethodABCDE (airway, breathing, circulation, disability, exposure).SAMPLE (symptoms, allergies, medications, past history, last meal, events).
PurposeTo assess and stabilize a patient who may have life-threatening injuries.To diagnose and treat a patient.

Key aspects of Secondary Assessment

  • Includes vital signs, physical examination, and health history.
  • Essential for identifying a diagnosis and treatment options.
  • Patient-specific.
  • Follows the primary assessment.