Secondary Assessment

• #Fowler
• A focused physical assessment to investigate potential causes of the patient's problem
• Everybody gets a secondary assessment after receiving a primary assessment
• First, visually inspect the patient. Once you have looked, you may begin to palpate slowly and systematically
• Auscultation is an important assessment tool, used to listen to sounds made by body systems like the lungs, heart, large blood vessels, and intestines
  • Auscultation comes after palpation in every case except for the abdomen. Always listen to the abdomen before palpating it to avoid disturbing the intestines and the sounds they may or may not be naturally making
• General Survey
  • Use the AVPU scale to determine the patient's broad mental status. If the patient is awake and alert, assess their posture and motor function
    • Assess if the patient is able to express their thoughts clearly
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      • If the patient is noted to have a notable deviation from baseline or if they appear altered with no known baseline, begin to consider what physical or mental causes may be present
    • Check the patient's orientation, ability to concentrate, and their immediate, short-term, and long-term memory
      • Ask the patient to repeat three to four random, unrelated words to test immediate memory
      • Ask the patient about recent events to test short-term memory
      • Ask the patient about the names of their family members to test long-term memory
    • Observe the patient's general grooming and personal hygiene, facial expressions, and speech pattern
      • The intent is not to judge the patient, but rather to assess their general state of life and their ability to take care of themselves
  • Obtain vital signs to establish a baseline of the patient's body functions
    • Track these vital signs throughout the duration of the call to obtain positive or negative trends and to refine the baseline
    • Visually inspect physical indicators before getting a number from the monitor
      • Capillary refill, condition of the oral mucosa, intercostal retractions, skin condition, etc
• Anatomic Functions
  • The skin is the largest organ in the body, serving as a layer of physical protection and thermal regulation
    • The epidermis is the pigmented layer that we typically see, mostly consisting of dead and dying cells that will be shed
    • The dermis contains the blood supply and nerve endings, as well as the hair follicles and sweat glands. This layer is what provides thermal regulation
    • Check the color, moisture, and temperature of the skin to assess circulatory adequacy
  • Examine the skull to check for integrity, wounds, and active bleeding
    • Expect lacerations on the skull to bleed profusely due to the extremely vascular nature of the skin in this area
    • Inspect symmetry and continuity of the face and skull
    • Inspect flexibility of the TMJ, placing the tip of your index finger in the associated depression in front of the ear
      • The TMJ is the joint that allows you space to open and close the jaw. Make note if the patient reports any tenderness, "clicks," or roughness opening or closing the jaw
    • In pediatric patients, check the appropriate presence and condition of the fontanelles
  • Test for visual acuity and visual fields by confrontation
    • Inspect the eyes for symmetry in size, shape, and contour
    • Inspect the sclera and conjunctiva by having the patient look up while you pull the eyelid down
    • Observe the speed and symmetry of pupillary reaction to light
    • Check for accommodation
      • Accommodation is the ability to cross the eyes to focus on an object close to the bridge of the nose. Check this gradually, moving an object closer to the nose and ensuring the patient keeps both eyes on the object. If one or both eyes drift away from the object, they have failed the test
  • Inspect the ears for deformities, lumps, lesions, tenderness, erythema, and any discharge
    • Discharge is an indicator of a severe problem
    • Evaluate the hearing capacity of both ears
  • The neck contains the spinal cord, blood vessels supplying the brain, and passages for air and food
    • Ensure the trachea is midline. Tracheal deviation is an extremely late sign that is indicative of imminent collapse, treat quickly
    • Palpate the thyroid gland and lymph nodes
      • Tender, swollen, and mobile lymph nodes indicate an infection
      • Hard or fixed nodes indicate a malignancy
    • Neck stiffness, especially in pediatric patients and when presenting with a fever, often indicates a viral infection
  • Check the chest for symmetry in shape and movement
    • Visualize the presence of any intercostal retractions or bulging
    • Ensure chest wall integrity
    • Auscultate the chest for lung sound abnormalities ([[Lung Sounds]])
  • [[Cardiac Assessment]]
  • Assess, auscultate, and palpate the abdomen, in that order
    • Check for signs of intra-abdominal bleeding
      • Look for discoloration around the umbilicus (Cullen's sign)
      • Look for discoloration over the flanks (Grey Turner's sign)
    • Ask the patient to point out any areas of pain or swelling before palpating, starting in areas distant to the pain while moving towards the pain
    • Look at the umbilicus for hernias, common in children under three years old
  • The genitalia are extremely vascular and nervous. Except in cases of trauma, assault, or abuse, you should rarely inspect this area
    • Whenever possible, have a provider of the same sex as the patient assess these areas
  • [[Musculoskeletal System]]
    • Test the range of motion including passive and active movement
      • Passive movement is you moving the joint, active movement is the patient moving it without assistance
      • Active and passive ranges of motion should be equal
• Neurological Exam
  • [[Cranial Nerves]]
  • Assess the patient's bilateral ability
    • Pushing and pulling against resistance
    • Arm drift while holding both arms out in front
    • Grip strength
    • Point-to-point touching
      • Using one finger, touch your own nose and then my outstretched finger
  • Perform the Romberg Test
    • Place both feet on the ground together
    • Falling or excessive swaying results in a fail
• Reassessment
  • ((fCwYuSJFd))
  • Start with reassessing mental status
  • Assess the effectiveness of interventions performed throughout the call
  • Assess unstable patients no less than once every five minutes, stable patients no less than once every fifteen minutes