Chapter 15: Secondary Assessment
Topics
● The Secondary Assessment
● Secondary Assessment of the Medical Patient
● Secondary Assessment of the Trauma Patient
● Detailed Physical Exam
The Secondary Assessment
Components of the Secondary Assessment
● Three categories of patients
○ Medical patient
○ Trauma patient
○ Unknown patient
● Physical examination
● Patient history
○ History of the present illness (HPI)
○ Past medical history (PMH)
● Vital signs
● Sign
○ Something you can see
● Symptoms
○ Something the patient can tell you
● Reassessment is a continual process
Secondary Assessment of the Medical Patient
● Assessment varies depending on patient’s ability to communicate
○ Responsive medical patient
■ Can answer history questions
○ Unresponsive medical patient
■ Cannot answer history questions
Responsive Medical Patient
● Obtain a patient history
● Perform physical exam
● Obtain baseline vital signs
● Administer interventions and transport the patient
Obtain a Patient History
● Obtain from patient first
● Obtain from family or bystanders if patient is unable to communicate
● Base questions of chief complaint or observations
● Ask open-ended questions
● Use SAMPLE mnemonic
, Tailoring the Physical Exam for Specific Chief Complaints
● Important information can be gained by tailoring history to patient’s chief complaint
● Ask questions pertinent to chief complaint
Perform a Physical Exam
● Usually brief
● Examine areas of concern based on chief complaint
Obtain Baseline Vital Signs
● Essential to assessment of medical patient
● Later assessments of vital signs will be compared to baseline
● Take manual blood pressure to verify accuracy of automatic blood pressure device
Administer Interventions and Transport the Patient
● Remember a decision for prompt transportation of critical patients or those with specific
complaints is part of a treatment plan
Pediatric Note
● Get on same level with child
● Put questions in simple language
● Gather information from caregivers
Unresponsive Medical Patient
● Begin with physical exam and baseline vital signs
● Then gather history from relatives or bystanders
● Do rapid assessment of entire body
Perform a Rapid Physical Exam
● Similar to head-to-toe physical exam for trauma patient
● Assess head, neck, chest, abdomen, pelvis, extremities, and posterior
● Neck
○ Jugular vein distention, medical identification devices
● Chest
○ Breath sounds
● Abdomen
○ Distention, firmness, or rigidity
● Pelvis
○ Incontinence of urine or feces
● Extremities
○ Pulse, motor, function, sensation, oxygen saturation, medical identification
devices
● Check for Medical ID devices
● Check pupils
● Assess:
Topics
● The Secondary Assessment
● Secondary Assessment of the Medical Patient
● Secondary Assessment of the Trauma Patient
● Detailed Physical Exam
The Secondary Assessment
Components of the Secondary Assessment
● Three categories of patients
○ Medical patient
○ Trauma patient
○ Unknown patient
● Physical examination
● Patient history
○ History of the present illness (HPI)
○ Past medical history (PMH)
● Vital signs
● Sign
○ Something you can see
● Symptoms
○ Something the patient can tell you
● Reassessment is a continual process
Secondary Assessment of the Medical Patient
● Assessment varies depending on patient’s ability to communicate
○ Responsive medical patient
■ Can answer history questions
○ Unresponsive medical patient
■ Cannot answer history questions
Responsive Medical Patient
● Obtain a patient history
● Perform physical exam
● Obtain baseline vital signs
● Administer interventions and transport the patient
Obtain a Patient History
● Obtain from patient first
● Obtain from family or bystanders if patient is unable to communicate
● Base questions of chief complaint or observations
● Ask open-ended questions
● Use SAMPLE mnemonic
, Tailoring the Physical Exam for Specific Chief Complaints
● Important information can be gained by tailoring history to patient’s chief complaint
● Ask questions pertinent to chief complaint
Perform a Physical Exam
● Usually brief
● Examine areas of concern based on chief complaint
Obtain Baseline Vital Signs
● Essential to assessment of medical patient
● Later assessments of vital signs will be compared to baseline
● Take manual blood pressure to verify accuracy of automatic blood pressure device
Administer Interventions and Transport the Patient
● Remember a decision for prompt transportation of critical patients or those with specific
complaints is part of a treatment plan
Pediatric Note
● Get on same level with child
● Put questions in simple language
● Gather information from caregivers
Unresponsive Medical Patient
● Begin with physical exam and baseline vital signs
● Then gather history from relatives or bystanders
● Do rapid assessment of entire body
Perform a Rapid Physical Exam
● Similar to head-to-toe physical exam for trauma patient
● Assess head, neck, chest, abdomen, pelvis, extremities, and posterior
● Neck
○ Jugular vein distention, medical identification devices
● Chest
○ Breath sounds
● Abdomen
○ Distention, firmness, or rigidity
● Pelvis
○ Incontinence of urine or feces
● Extremities
○ Pulse, motor, function, sensation, oxygen saturation, medical identification
devices
● Check for Medical ID devices
● Check pupils
● Assess:
