The document discusses the process of secondary assessment in nursing. It begins with an overview stating that secondary assessment is brief, performed after primary assessment and resuscitation, and is useful for discovering occult problems in patients with poor histories. The goals of secondary assessment are then outlined as discovering all non-life threatening abnormalities or injuries. Key components of secondary assessment are described in detail and include taking a full set of vital signs, focused adjunct exams, providing comfort measures, obtaining a thorough medical history, and conducting a head-to-toe physical exam. The document provides guidance on assessing each body system.

1. Secondary Assessment
K. A. V. Hewapathirana (RN, RM, BSc)
Senior Tutor
PBCN -Colombo

2. Secondary Assessment
 Is brief
Perform after the primary
assessment & resuscitation
Is valuable for discovering
occult problems in patients
with a poor or confusing
history

3. Goal of the secondary
assessment is:-
To discover all other
abnormalities or injuries
that are not life
threatening

4. F- Full set of vital signs /
Focused adjuncts/ Facilitate
family presence
G- Give comfort measures
H- History & head to toe
assessment
I- Inspect posterior surfaces

6.  Blood pressure
 Pulse – rate / rhythm / quality
Central pulse Peripheral pulse
Apical Radial
Carotid Brachial
Femoral Posterior
tibialis
Dorsalis
pedis
 Temperature
 Respiration- rate/ depth/ quality

8.  Focused adjuncts
For patients with significant abnormalities in the
primary assessment, consider performing the following
interventions at this assessment and intervention
process.
 Cardiac monitoring
 Sp O2
 End tidal CO2 monitoring
 Gastric tube - risk of aspiration
risk of respiratory compromise
 Indwelling catheter
 Laboratory studies
 Imaging studies – X-Rays
CT scan
MRI
 Need for tetanus immunization

9.  Facilitate family presence
 Family presence may reduce anxiety of the
patient
 Assess the family’s desire to present at the
bedside
 Source for assessment

10.  Give comfort measure
 Assess pain ( using PQRST )
{ Provocation , quality , region/radiation,
severity , temporal factors }
 Position of comfort if not contraindicated
 Splint , elevate , injured extremities
 Use age-appropriate distraction techniques
Administer pharmacologic therapy as
ordered (analgesics , NSAID , narcotics )

11. History
 History of present illness/ injury/ chief
complaint, immunization, allergies,
medications, past medical history, events
surrounding the condition, diet.
 Content & time of most recently ingested
food, alcohol
 Efforts to relieve symptoms ( home
remedies , medication, physician visits)

12.  Past medical history
 General health status
 Current or pre-existing disease/illness
 Respiratory ,neurologic, endocrine, hepatic,
haematological diseases or risk factors
 Infections, immunosupre sion, autoimmune,
psychological related conditions.
 Recent trauma –blunt/ penetrating
 Substance or alcohol use/abuse
 Detoxification history
 Smoking history

13. Last normal menstrual period –for
female pts
Environmental exposures
Obesity, malnourishment, eating
disorders history
Related situations for present
problem or current event
Previous episodes – No
Yes- duration,
date, Rx
Previous injury

14.  Current medications
 Allergies – for medication
for food
others
 Immunization status – for tetanus
for childhood illnesses
 Psychological / social / environmental factors
Collection of a complete social and psychological
history may be limited. However in some situations this
information is essential.
 Risk factors- smoking, substance use, psychiatric history
 Age appropriate behaviour
 Occupation

15.  Hobbies
 Family & support system
 Responsibilities- self, family, occupational,
community
 Living accommodations- house, apartment,
homeless

16. Head to toe assessment
A complete head to toe assessment is
necessary for all critically ill or injured
patients .It is not required for patients with
only minor injuries or symptoms related to
one body system.
General appearance
Behaviour
Odours
Acetone-indicative of ketosis
Gasoline-indicative of spilled fuel
Urine
Faeces

17. Metallic-indicative of blood loss
Chemicals
Others
Gait
Hygiene
Level of distress/ discomfort/ critically ill

18.  Skin/ mucous membrane/ nail beds
Inspection
(Integrity, lacerations, ecchymosis, abrasions,
puncture wounds, burns, foreign objects)
 Colour
Pink, pallor, erythema, jaundice, cyanosis
 Rash/ Lesions
 Abscess formation
 Cellulites, lymphagitis
Palpation
 Moisture/ Turgor
Dry , moist, diaphoresis, edema

19. Cntd……
 Temperature
Cool, cold, warm

20.  Head & Face
Inspection
Skin integrity, lacerations ,abrasions ,puncture
wounds ,burn , foreign objects
Ecchymosis- bilateral periorbital ecchymosis( black
eyes) may indicate basilar skull fracture
Oedema
Presence of pink or grey tissue-possible brain
tissue damage
Facial features-symmetry/ asymmetry
Malocclusion of teeth

21. Palpation
 Bony deformity-depression , tenderness
 Open fracture
 Loose teeth
Eyes
Inspection
 Skin integrity-lacerations ,ecchymosis, abrasions,
puncture wounds ,foreign objects
 Gross visual acuity
 Pupil size ,equally reaction to light
 Sclera/ conjunctiva-colour, bleeding ,excessive
tearing, discharges, foreign objects ,ulcerations
 Lid oedema
 Ptosis
 Excessive blinking or inability to open eyes
 Exopthalmus
 Contact lensess

22. Inspection
 Integrity, lacerations, ecchymosis, abrasions,
puncture wounds, burns, foreign objects
 Blood presence –external ear or canal
 Clear fluid –CSF leakage indicate an open skull
fracture.
 Ecchymos- behind ear over the mastoid bone-battle’s
sign –may indicative of basilar skull
fracture
 Exposed cartilage
 Purulent discharge
 External haematoma

23. Inspection
- skin integrity-lacerations ,ecchymosis,
abrasions, puncture wounds, burns, foreign –
objects
-bleeding/ discharges
-deformity/swelling
-Septal hematoma
rhinorrhoea-
-palpation
bony tenderness
deformity

24.  Inspection
 Skin integrity-lacerations, ecchymosis ,abrasions,
puncture wounds,burns,foreign objects.
 Oedema
Palpation
 Tracheal position
 Neck veins-distended/flat
 Subcutaneous emphysema-may indicate
disruption of trachea or bronchial tree
 Step-off along cervical spine-tenderness or
muscle spasm

25.  Inspection
 Accessory muscle use
 Bony deformities
Skin integrity-lacerations ,abrasions puncture
wounds, burns ,foreign objects.

26.  Chest
Inspection
Accessory muscle use
Bony deformities
Skin integrity
Ecchymosis
Palpation
Tenderness
Crepitus
Deformity
Subcutaneous emphysema

27.  Auscultation
Breath sounds-
Bilateral equality ( normal, decreased,
absent)
Any adventitious sounds ( wheezes,
rhonchi)
Dyspnoea
Heart sounds-
Muffled
Murmurs
Gallops

28.  Abdomen
 Inspection-
Laceration, Abrasion, Puncture wounds,
burns, rashes, surgical scars
 Palpation-tenderness,
soft, rigid, masses
 Auscultation-bowel
sounds ( present, absent, hypo
active, hyper active)

29.  Pelvis/ Perineum
 Inspection-
Skin integrity, bleeding(urethral, genital,
rectal)
Genital lesions or discharges
 Palpation-
Pelvic tenderness

30. Extremities
inspection
 Skin integrity
 Closed fractures
 Open fractures
 Deformities
 Oedemas
Palpation
 Tenderness
 Instability
 crepitus

31.  Motor function
 flexion /extension
 Symmetry of strength
 Range of motion
 Sensory function
 Sharp/dull
 Circulatory status
 Colour/skin temperature
 Pulses distal to injury
 Capillary refill

32. Posterior surfaces
 patient’s back and posterior aspects of
arms and legs
 Should be evaluated for the presence of
bleeding, abrasions ,wounds,
haematomas, ecchymosis, rashes, lesions,
oedema
 The vertebral column
-tenderness ,deformity
Logroll the patient to maintain spinal alignment if there is any potential
for spinal injury

33.  Group Assignment
To prepare a history taking format
• Individual Assignment
 Physical assessment presentation of an
emergency patient according to given format