Emergency Secondary Assessment - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Do not begin the secondary assessment until the primary assessment is complete and resuscitation procedures have been initiated as indicated.

Continue to monitor airway, breathing, circulatory, and neurologic status during the secondary assessment. If any life-threatening problems arise, return to the primary assessment and intervene as indicated.

Prioritize and initiate interventions for injuries or conditions discovered in the secondary assessment after the entire head-to-toe examination is complete.

OVERVIEW

The purpose of the secondary assessment is to rapidly and systematically assess critically ill and injured patients from head to toe to identify all injuries and signs of illness and to rapidly and systematically assess critically ill patients when the cause of their signs and symptoms is unclear. Interventions for injuries or conditions discovered in the secondary assessment should be prioritized and initiated after the entire secondary assessment is complete.

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• If the patient has been injured, instruct the patient to avoid moving until a spinal injury has been ruled out.
• Explain the procedure to the patient and family and why it is being performed, as time and the patient’s condition allow.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Ensure that the primary assessment is complete and interventions have been initiated for life-threatening conditions.
2. Clean hands and don gloves. Don additional personal protective equipment (PPE) based on the risk of exposure to bodily fluids or infection precautions.
3. Assess for risk factors for spinal injury.

Preparation

1. If the patient is at risk for spinal injury, ensure that spinal alignment is maintained throughout each step of the primary and secondary assessments.

PROCEDURE

1. Perform the secondary assessment using a systematic approach to ensure that no step is forgotten. The steps below follow the mnemonic F-G-H-I-J (to continue the primary assessment mnemonic, A-B-C-D-E):^{undefined#ref4">4}

   F = full set of vital signs and family presence
   G = get monitoring devices and give comfort (using the mnemonic L-M-N-O-P)
   H = history and head-to-toe assessment (using the mnemonics M-I-S-T and S-A-M-P-L-E)
   I = inspect posterior surfaces
   J = just keep reevaluating

F = Full Set of Vital Signs and Family Presence

1. Obtain and trend readings for blood pressure, pulse, respiratory rate, peripheral oxygen saturation (SpO₂), and temperature at regular intervals.
2. Offer the family the opportunity to be with the patient in the treatment area if appropriate. Provide a support person to be with them to answer questions and explain procedures.

   Rationale: Evidence shows that family presence during trauma resuscitation helps the family cope and supports the patient.

G = Get Monitoring Devices and Give Comfort

1. Follow the mnemonic L-M-N-O-P when obtaining resuscitation monitoring devices and supports.

L = Laboratory Studies

1. Obtain appropriate laboratory tests, such as arterial blood gas (ABG) analysis, lactic acid level, and type and crossmatch if indicated.
2. Label the specimen in the presence of the patient.⁵
3. Place the labeled specimen in a biohazard bag and transport it to the laboratory.

M = Monitoring (Cardiac)

1. Monitor cardiac rate and rhythm. Arrhythmias, such as premature ventricular contractions (PVCs), atrial fibrillation, or S-T segment changes, may indicate a blunt cardiac injury. Pulseless electrical activity may suggest cardiac tamponade, tension pneumothorax, or profound hypovolemia.

N = Nasogastric or Orogastric Tube

1. Insert a nasogastric or orogastric tube if indicated or prescribed to relieve gastric distention, which helps optimize lung inflation, and to prevent vomiting and aspiration.

   Avoid the nasogastric route in patients with a suspected head injury or mid-face fractures.

O = Oxygenation and Ventilation (SpO₂, End-Tidal Carbon Dioxide [ETCO₂])

1. Monitor oxygenation by implementing pulse oximetry (if not performed previously). Remember that pulse oximetry is a measurement of SpO₂ and is not evidence of ventilation. Once the patient is stabilized, consider weaning supplemental oxygen to maintain a room air SpO₂ of 94% or greater, which is considered adequate oxygenation, to prevent hyperoxia.⁴

   Do not rely on pulse oximetry readings in a patient with poor perfusion; they may not be accurate. Assess the quality of the plethysmographic waveform if there is any doubt.

2. Assess ventilation by monitoring ETCO₂ levels via capnography. Normal values range from 35 to 45 mm Hg.

P = Pain Assessment and Management

1. Assess pain using an appropriate, validated pain assessment scale and initiate pharmacologic and nonpharmacologic interventions as indicated.

H = History and Head-to-Toe Assessment

1. Obtain a prehospital report of the incident or illness. A helpful mnemonic is M-I-S-T:

   M = mechanism of injury
   I = injuries sustained
   S = signs and symptoms before arrival
   T = treatment before arrival

2. Obtain the patient’s history. A helpful mnemonic is S-A-M-P-L-E.

   S = symptoms associated with the injury or illness
   A = allergies and tetanus status
   M = medications currently used, especially anticoagulants
   P = past medical history (including hospitalizations and surgeries)
   L = last oral intake and output (last menstrual period if female of childbearing age)
   E = events and environmental factors related to the injury or illness

3. Assess the patient from head to toe.

Head and Face

1. Inspect the head and face for wounds, deformities, discolorations, or bloody or serous drainage from the nose or ears. Palpate the entire head and face for wounds, deformities, or tenderness.
2. In the conscious and cooperative patient, evaluate extraocular movements, gross vision, and dental occlusion.
3. Note any unusual odors, for example, gasoline, fruity breath, or ethanol.

Neck

1. If necessary, remove the anterior portion of the cervical collar while another person maintains manual stabilization of the head and neck.
2. Inspect the anterior neck for wounds, jugular venous distention, discolorations, or deformities. Palpate the anterior neck for deformities, crepitus, tenderness, or tracheal deviation (best palpated in the notch above the manubrium).
3. Gently palpate the posterior neck from the base of the skull to the upper back for wounds, deformities, tenderness, or muscle spasms.

Chest

1. Inspect the anterior and lateral chest for wounds, deformities, discolorations, respiratory expansion, symmetry, and paradoxical movement. Palpate the anterior and lateral chest for deformities, tenderness, or crepitus.
2. Auscultate breath sounds to determine whether they are present and equal bilaterally and note any abnormal sounds, such as crackles and wheezes.
3. Auscultate heart sounds to determine whether they are clear or muffled.

Abdomen and Flanks

1. Inspect the abdomen and flanks for wounds, discolorations, or distention.
2. Auscultate all quadrants for the presence of bowel sounds.
3. Gently palpate the abdomen and flanks for tenderness, guarding, rigidity, or masses.

   To facilitate patient cooperation, palpate known painful areas last.

Pelvis and Perineum

1. Inspect the pelvic area and perineum for wounds, deformities, discolorations, or bleeding from the urinary meatus, vagina, or rectum.
2. Palpate for pelvic tenderness, crepitus, or instability by gently pressing in on the anterosuperior iliac crests bilaterally and pushing down on the pubic symphysis.
3. Consider placement of an indwelling urinary catheter.

   Placement of an indwelling urinary catheter is contraindicated if there is blood at the urinary meatus, perianal ecchymosis, or scrotal ecchymosis.

Extremities

1. Inspect all extremities for wounds, deformities, or discolorations.
2. Palpate all extremities for tenderness, deformities, muscle spasms, skin temperature and moisture, and distal pulses.
3. If the patient is conscious, determine gross motor and sensory function by having the patient wiggle the toes and fingers and asking whether the patient can feel your touch.

I = Inspect Posterior Surfaces

1. In the injured patient, obtain assistance to maintain cervical spine alignment and support injured extremities while log rolling the patient to the side.

   Avoid rolling the patient onto an injured extremity or side if possible. If necessary, for adequate assessment of posterior surfaces, roll the patient to both sides.

   The log roll maneuver can result in spinal and pelvic movement. Carefully consider the risks and benefits of performing this maneuver, especially if the potential for spinal cord injury or pelvic fracture is significant.¹

   When spinal or pelvic injuries are suspected, radiographs are recommended before logrolling the patient.⁴

2. Inspect the posterior surfaces for wounds, deformities, or discolorations. Palpate all posterior surfaces for wounds, deformities, or muscle spasms.
3. At this point, the practitioner may perform a rectal examination to assess sphincter tone, presence of injury to the pelvis or rectal mucosa,² and the presence of gross or occult blood.

   Prostate position as determined by rectal examination is not a reliable indicator of urethral injury.²

4. Remove the backboard or transferring device as indicated.

J = Just Keep Reevaluating

1. Continue ongoing monitoring and evaluation of the patient. Reevaluation should include the primary survey, vital signs, level of pain and any injuries identified. A helpful mnemonic is V-I-P-P:

   V = vital signs
   I = injuries sustained and interventions
   P = primary survey
   P = level of pain

Completing the Procedure

1. Take the patient’s temperature, if not done earlier.
2. Perform a focused assessment of any injuries or abnormalities found.
3. Obtain more detailed information about the patient’s medical history, including pertinent immunizations, current medications (prescription, over the counter, and herbal), and past medical and surgical history.
4. Discard supplies, remove PPE, and clean hands.
5. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Evaluate the patient’s evolving condition by monitoring these indicators (and any others that apply) and intervene as needed:
   1. Airway patency
   2. Breathing effectiveness
   3. Pulse, skin temperature, capillary refill, and color
   4. Neurologic status
   5. Vital signs
   6. Urine output
2. Assess, treat, and reassess pain.
3. Implement spinal protection measures and other interventions as indicated by examination findings.
4. Obtain diagnostic tests as indicated.
5. If the family is not already in the treatment area, offer them the opportunity to be with the patient now. Provide a support person to answer questions and explain procedures.

EXPECTED OUTCOMES

• Complete systematic assessment of a critically ill or injured patient in whom the cause of signs and symptoms is unclear
• Identification of all injuries and abnormalities

UNEXPECTED OUTCOMES

• Patient deterioration may result from a failure to recognize and intervene appropriately for life-threatening conditions that develop or worsen during the secondary assessment.
• In the injured patient, trauma to the spinal cord may result from a failure to maintain spinal alignment and stabilization throughout the secondary assessment.
• Patient deterioration may result from a failure to complete the secondary assessment and prioritize interventions before initiating them.
• Patient deterioration may result from intervening for noncritical problems, such as extremity fractures, before correcting life-threatening conditions.

DOCUMENTATION

• Vital signs
• Injuries and conditions found in the secondary assessment
• Mechanism of injury or history of present illness, if known
• Interventions performed (including name and dosage of medications administered)
• Unexpected outcomes and related interventions
• Patient’s response to interventions
• Collection of evidence and chain of custody for evidence handoffs, if applicable
• Education

PEDIATRIC CONSIDERATIONS

• Infants and young children have immature thermoregulatory capability and are susceptible to iatrogenic hypothermia. Keep pediatric patients covered and provide warming as indicated.⁴
• Unlike adults and older children, the infant’s skull can accommodate blood loss significant enough to cause hypotension and shock. The infant’s anterior fontanels should be observed for bulging.
• Pediatric patients should be weighed as soon as possible because medication doses, fluid resuscitation, and other interventions are influenced by the patient’s size. If obtaining a weight is not feasible, a length-based resuscitation tape can be used to estimate weight.
• The normal range for vital signs in pediatric patients varies by age (Table 1). The heart and respiratory rates may be altered by fear, pain, and anxiety, in addition to physiologic problems, such as hypoxia and hypovolemia. In pediatric patients, blood pressure may be maintained in the presence of significant hypovolemia. Therefore, other assessments of circulatory status (heart rate, capillary refill, skin color, and so forth) should be monitored closely. Hypotension is defined as a systolic blood pressure less than the fifth percentile for the patient’s age.^3,6

OLDER ADULT CONSIDERATIONS

• A supine position may be poorly tolerated and cause respiratory distress in older adults, especially those with significant preexisting pulmonary or cardiac disease.
• Older adults with kyphosis may require additional support under the head to maintain their normal (baseline) head and neck position for spinal stabilization.
• In older adults, the decreased sensitivity of baroreceptors, decreased response to beta stimulation, and medications may prevent a compensatory tachycardia in response to decreased systemic perfusion.
• Older adults may have less subcutaneous fat and lose body heat easily. Keep them covered and provide warming as indicated.
• Older adults are at increased risk for pressure ulcers. Pad bony prominences when immobilizing older adults and remove them from backboards as soon as possible.

REFERENCES

1. Alson, R.L., Augustine, J.J. (2020). Chapter 10: Spinal trauma and spinal motion restriction. In R.L. Alson, K.H. Han, J.E. Campbell (Eds.), International trauma life support for emergency care providers (9th ed., pp. 182-208). Hoboken, N.J.: Pearson Education, Inc.
2. American College of Surgeons (ACS). (2018). Chapter 5: Abdominal and pelvic trauma. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 82-101). Chicago: Author.
3. Giordano, D. (2023). Chapter 7: The child in need of stabilization. In Emergency Nurses Association (ENA), ENPC: Emergency nursing pediatric course: Provider manual (6th ed., pp. 95-116). Burlington, MA: Jones & Bartlett Learning.
4. Jamerson, L. (2023). Chapter 5: Initial assessment. In Emergency Nurses Association (ENA), ENPC: Emergency nursing pediatric course: Provider manual. (6th ed., pp. 69-82). Burlington, MA: Jones & Bartlett Learning.
5. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved May 7, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
6. Topjian, A.A. and others. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S469-S523. doi:10.1161/CIR.0000000000000901 Retrieved May 7, 2024, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: June 2024