Emergency Secondary Assessment (Pediatric) - 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 are initiated based on the findings of the primary assessment.

Immediately stop the secondary assessment and address any life-threatening conditions if the patient’s condition deteriorates.

OVERVIEW

The secondary assessment is a rapid and systematic assessment of a critically ill or injured patient from head to toe to identify all signs of illness and injuries or of a patient who is seriously ill when the cause of signs and symptoms is unclear.^{undefined#ref2">2}

There are two major components of the secondary assessment: the focused history and the focused physical assessment, both based on the presenting signs and symptoms.

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.
• Explain the secondary assessment, including the steps and rationale.
• Explain how the patient and family can assist with the procedure.
• Instruct the patient (as developmentally appropriate) to avoid moving until a spinal cord injury has been ruled out. Instruct the family not to move the patient.
• Explain that if the patient feels pain during the procedure, it will be addressed.
• Explain that the patient may feel anxiety during the procedure.
• 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. Proceed immediately to the next step if already wearing personal protective equipment (PPE), including gloves and—if indicated—a mask, eye protection, and fluid-resistant gown. Otherwise, perform hand hygiene and don gloves and appropriate PPE based on the patient’s signs and symptoms or infection precautions. Don gown, mask, and eye protection or face shield if the risk of splashing exists.

Preparation

1. If the patient is at risk for spinal injury, ensure that spinal motion restriction is maintained throughout each step of the primary and secondary assessments.
2. Initiate interventions for septic shock.³
   1. Administer fluids (10 ml/kg to 20 ml/kg aliquots) and frequently reassess the patient.
   2. Administer either epinephrine or norepinephrine as an initial vasoactive infusion; if neither is available, dopamine may be considered.
   3. Administer stress-dose corticosteroids if the patient is unresponsive to fluids and requires vasoactive support.

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):²

   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 mnemonic 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 the patient’s vital signs, including pulse, respirations, temperature, blood pressure, oxygen saturations, and end-tidal carbon dioxide levels, as indicated.
2. Compare vital sign values obtained to the normal range for vital signs by age (Table 1) (Table 2) (Table 3).

   Heart and respiratory rates may be altered by fear, pain, and anxiety, or by physiologic problems such as hypoxia and hypovolemia.

   Do not rely on blood pressure alone to assess perfusion. Pediatric patients can maintain a normal blood pressure in the presence of significant hypovolemia. Assess perfusion with level of consciousness, heart rate, capillary refill, skin color, and pulses.

   Immediately stop the secondary assessment and address any life-threatening conditions if the patient’s condition deteriorates. Return to the primary assessment and intervene before returning to the secondary assessment.

3. If the patient’s condition requires invasive or resuscitative measures, assign a health care team member or support person to provide the family with support and explanations about what is occurring.

G = Get Monitoring Devices and Give Comfort

1. Follow the mnemonic L-M-N-O-P when obtaining resuscitation monitoring devices and supports.
   1. L = Laboratory studies: Send appropriate specimens to the laboratory for analysis and to obtain a point-of-care glucose.
   2. M = Monitoring: Place the patient on a cardiopulmonary monitor.
   3. N = Nasogastric or orogastric tube: Insert a gastric tube, if needed.
   4. O = Oxygenation and ventilation (peripheral oxygen saturation [SpO₂], end-tidal carbon dioxide [ETCO₂]):
      1. Monitor oxygenation by implementing pulse oximetry (if not performed previously). Pulse oximetry is a measurement of SpO₂ and is not evidence of ventilation. An SpO₂ of 94% or greater on room air is considered adequate oxygenation.³ Once the patient is stabilized, consider weaning supplemental oxygen to maintain a room air SpO₂ of 94% or greater to prevent hyperoxia.²

         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.
   5. P = Pain assessment and management: Assess the patient for pain, using a developmentally appropriate, validated pain assessment scale.

H = History and Head-to-Toe Assessment

1. Obtain a focused history using the SAMPLE mnemonic:²

   Signs and symptoms: onset and nature, such as difficulty breathing, fever, or pain
   Allergies: medications, foods, environmental, substances (e.g., latex), including reactions (e.g., rash, anaphylaxis)
   Medications: prescription, over the counter, herbal; dose, times, duration, missed doses; ask about alcohol or substance use.
   Past medical: illnesses, hospitalizations, surgeries, immunizations, birth history, relevant family history
   Last oral intake and Last menstrual period: usual diet; time and nature of last intake; if of childbearing age, obtain the last menstrual period
   Events: regarding current illness or injury; mechanism of injury; treatment before arrival

2. Begin the head-to-toe assessment.

Head and Face

1. Inspect for wounds, deformities, swelling, asymmetry, discolorations, and bloody or serous drainage from the nose or ears.
2. Palpate the entire head and face for swelling, deformities, and tenderness; palpate the fontanels in infants.

   The anterior fontanelle does not usually close until 18 months of age. A bulging fontanelle may indicate increased intracranial pressure.² A sunken fontanelle may indicate dehydration.

3. In a conscious and cooperative patient, evaluate extraocular movements, gross vision, and dental occlusion.
4. Identify any unusual odors, such as gasoline, fruity breath, or ethanol.

Neck

1. If the patient is wearing a cervical collar, remove the anterior portion as an assistant maintains manual stabilization of the head and neck.
2. Inspect the anterior neck for wounds, jugular venous distention, lymphadenopathy, discolorations, deformities, and the use of accessory muscles for breathing.
3. Palpate the anterior neck for deformities, subcutaneous emphysema, tenderness, or tracheal deviation (best palpated in the notch above the manubrium).
4. Gently palpate the posterior neck from the base of the skull to the upper back for deformities, bony crepitus, or tenderness.
5. Replace the cervical collar when the examination is complete.

Chest

1. Inspect for signs of increased work of breathing (e.g., accessory muscle use, retractions), wounds, scars, deformities, discolorations, chest expansion, symmetry, impaled objects, paradoxic movement, and surgically implanted devices, such as venous access devices.
2. Palpate the anterior and lateral chest for deformities, tenderness, subcutaneous emphysema, or bony crepitus.
3. Auscultate breath sounds to determine whether they are present and equal bilaterally; identify any adventitious sounds, such as crackles and wheezing.
4. Auscultate heart sounds to determine rate and rhythm and whether the sounds are clear or muffled; identify the presence of any murmurs, gallops, or friction rubs.

Abdomen and Flanks

1. Inspect for wounds, discolorations, distention, or surgically implanted devices, such as feeding tubes.
2. Auscultate all quadrants for the presence of bowel sounds.
3. Gently palpate the abdomen for tenderness, guarding, rigidity, or masses.

   Palpate the areas that are known to be painful last to facilitate the patient’s cooperation.

   If the patient is uncooperative with palpation of the abdomen, assess for rigidity by palpating the abdomen when the patient inhales, which relaxes the abdominal muscles.

   Unilateral pain is a significant finding.

Pelvis and Perineum

1. Inspect the perineum for wounds; deformities; discolorations; or bleeding from the urinary meatus, vagina, or rectum.

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

2. Palpate for pelvic tenderness, crepitus, or instability by gently pressing in on the anterior superior iliac crests bilaterally and gently pushing down on the pubic symphysis.

   If there is crepitus or instability when assessing the anterior superior iliac crests, do not assess the symphysis pubis.

Extremities

1. Inspect all extremities for wounds, deformities, swelling, discolorations, positioning, or abnormal movement.
2. Palpate all extremities for tenderness, deformities, skin temperature and moisture, and distal pulses.
3. If the patient is conscious, determine gross motor and sensory function.

I = Inspect Posterior Surfaces

1. If able, have the patient sit up or roll over.
2. If the mechanism of injury indicates a suspicion for a spinal cord injury, obtain assistance to maintain cervical spinal motion restriction and support the injured extremities while log rolling the patient to the side.

   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.²

3. Inspect the posterior surfaces for wounds, deformities, or discolorations.
4. Palpate all posterior surfaces for wounds, deformities, bony crepitus, tenderness, or muscle spasms.
5. If the patient is on a long spine board, remove it 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. Remove PPE and perform hand hygiene.
2. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Follow the organization’s practice for blood pressure management, assessment and treatment of seizures, and targeted temperature management.³
2. Frequently reassess the patient’s airway, breathing, and circulation, as well as any areas of abnormalities, to identify changes and possible deterioration in the patient’s condition.
3. Perform frequent monitoring of vital signs.
4. Assess, treat, and reassess pain.
5. Anticipate and plan for procedures, diagnostic tests, consultations, and transfers based on the findings from the secondary assessment.

EXPECTED OUTCOMES

• A complete systematic assessment is performed on a patient in whom the cause of signs and symptoms is unclear.
• All injuries and abnormalities are identified.

UNEXPECTED OUTCOMES

• Failure to recognize and intervene appropriately in life-threatening conditions that develop or worsen, resulting in the patient’s condition deteriorating
• Intervention for noncritical problems, such as extremity fractures, before correcting life-threatening conditions, resulting in the patient’s condition deteriorating

DOCUMENTATION

• Conditions found, including pertinent positive and negative findings
• Interventions performed to address life-threatening conditions and the patient’s response to interventions
• Interventions performed to address any non–life-threatening conditions and the patient’s response to interventions
• Education
• Unexpected outcomes and related interventions

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. 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.
3. 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 10, 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