The secondary assessment is a systematic process used in emergency care to identify injuries or medical conditions that are not immediately life-threatening. It follows the primary assessment, which focuses on stabilizing urgent issues related to the patient’s airway, breathing, and circulation. Once immediate life threats are managed, the secondary assessment begins, focusing on a detailed evaluation and thorough history collection. This phase gathers information about the patient’s condition and the events leading up to the incident. This approach helps medical professionals form a complete clinical picture, guiding subsequent treatment and preparing the patient for definitive care.
Gathering Patient History
The history-taking phase represents the collection of subjective data, relying on information provided by the patient, family members, or bystanders. This narrative is accomplished using specific mnemonic tools to ensure no relevant details are missed regarding the patient’s current complaint and medical background. For general medical or non-trauma complaints, the SAMPLE history is employed to structure the interview:
- Signs and Symptoms (S), capturing what the professional observes and what the patient reports feeling.
- Allergies (A), including medications, food, or environmental substances that might affect care.
- Medications (M), including prescribed, over-the-counter drugs, and supplements.
- Pertinent past medical history (P), such as previous surgeries or chronic illnesses.
- Last oral intake (L), noting the time and content of the patient’s last meal, which is important if surgery is anticipated.
- Events (E) leading up to the incident or complaint, helping determine the mechanism of injury or illness progression.
When the patient’s chief complaint involves pain, the specialized mnemonic OPQRST is used to gain a detailed understanding of the sensation:
- Onset (O) asks what the patient was doing when the pain started.
- Provocation or Palliation (P) inquires if anything makes the pain better or worse, such as movement or rest.
- Quality (Q) assesses the pain description, using terms like sharp, dull, or crushing.
- Region and Radiation (R) establishes where the pain is located and if it moves to other parts of the body.
- Severity (S) quantifies the pain, typically using a 0-to-10 scale.
- Time (T) asks how long the pain has been present and if it has changed since it began.
This systematic gathering of subjective data provides the narrative foundation that guides the subsequent physical assessment.
The Comprehensive Physical Examination
The comprehensive physical examination is the objective data collection phase, involving a hands-on, systematic inspection of the patient’s body to find signs of injury or illness. The approach is either a focused exam, targeting an isolated complaint like a fractured arm, or a rapid head-to-toe assessment for patients with significant trauma or those who are unresponsive. This systematic process generally moves from the head downward, using inspection, palpation, and auscultation.
The examination begins with the Head and Neck, where the professional inspects for deformities, bruising (like Battle’s sign behind the ears, which suggests a skull fracture), and drainage from the ears or nose. Gentle palpation of the scalp and face checks for tenderness or bony instability. The neck is examined for alignment, swelling, and any abnormal pulsations.
Moving to the Chest, the assessor looks for unequal chest rise, bruising, or open wounds, which can indicate serious internal damage. Palpation can reveal crepitus, a crackling sensation from air trapped under the skin, often from a collapsed lung. Auscultation, using a stethoscope, determines if breath sounds are present and equal in both lungs and checks for abnormal sounds like wheezes or rales.
The Abdomen is inspected for distention or discoloration before being gently palpated in all four quadrants to check for guarding, rigidity, or masses that suggest internal bleeding or organ injury.
The Pelvis and Extremities are assessed for stability, deformity, and open fractures. The pelvis is often gently compressed to check for fractures that could cause major blood loss. The limbs are checked for circulation, sensation, and motor function, ensuring nerve and vascular supply is intact. Finally, the Posterior surface, including the back and spine, is examined by carefully rolling the patient to inspect for hidden injuries or tenderness along the spinal column.
Physiological Monitoring and Reassessment
The secondary assessment incorporates the measurement of physiological parameters. These measurements include the Pulse Rate, the Respiratory Rate, and Blood Pressure, which is measured to assess circulatory status and perfusion. Skin condition (color, temperature, and moisture) offers a rapid, non-invasive gauge of blood flow.
Oxygen saturation (SpO2) is measured using a pulse oximeter, providing the percentage of oxygen carried by hemoglobin in the blood. Neurological status, often assessed using the Glasgow Coma Scale (GCS), is also measured to track the patient’s level of consciousness and responsiveness. These vital signs establish a baseline against which any subsequent changes can be compared.
The final, continuous step in the process is Reassessment, which involves the periodic repetition of the primary and secondary assessments. Because a patient’s condition can change rapidly, reassessment ensures that new life threats or deterioration are promptly recognized. For unstable patients, this process may occur every five minutes, while stable patients are reassessed every fifteen minutes. If any unexpected change in the patient’s status occurs, the medical professional must immediately return to the primary assessment to manage the evolving issue.