A secondary assessment is a methodical evaluation performed by healthcare professionals after immediate life-threatening conditions have been addressed and stabilized. Its purpose is to identify non-life-threatening conditions or injuries not apparent during the initial rapid assessment. This comprehensive examination gathers detailed information about a patient’s health status and specific complaints.
Differentiating Primary and Secondary Assessments
The primary and secondary assessments serve distinct purposes in patient care. A primary assessment focuses on identifying and managing immediate life threats, often using the ABCDE mnemonic: Airway, Breathing, Circulation, Disability, and Exposure. This rapid evaluation prioritizes interventions to stabilize life-threatening issues. Once immediate concerns are addressed and the patient’s condition is stable, the secondary assessment begins. This more thorough examination uncovers additional injuries or medical conditions.
Patient History and Vital Signs
Patient History
Gathering a detailed patient history is an important step in the secondary assessment, often guided by the “SAMPLE” mnemonic:
- S: Signs and Symptoms, which are objective observations and subjective complaints.
- A: Allergies, including reactions to medications, foods, or environmental factors.
- M: Medications, encompassing prescription drugs, over-the-counter remedies, and supplements.
- P: Past Medical History, covering previous illnesses, surgeries, and chronic conditions.
- L: Last Oral Intake, noting when the patient last ate or drank, relevant for potential procedures.
- E: Events leading up to the illness or injury, providing context for the current situation.
Vital Signs
Following the patient history, obtaining vital signs provides objective data about the body’s basic functions. These include heart rate, respiratory rate, blood pressure, and temperature. Oxygen saturation levels show the percentage of oxygen-carrying hemoglobin in the blood.
The Head-to-Toe Physical Examination
A systematic head-to-toe physical examination is a key part of the secondary assessment, designed to identify injuries or conditions not found during the primary assessment or history. This survey involves looking for visible signs, listening for abnormal sounds, and feeling for deformities, tenderness, or swelling. The examination begins with the head and face, inspecting for wounds, deformities, or drainage from the nose or ears, and assessing pupils for size and reactivity.
Moving down, the neck is examined for tenderness, swelling, or signs of injury to the cervical spine. The chest is assessed for symmetry of movement, wounds, and auscultated for clear breath and heart sounds. The abdomen is inspected for distension or bruising, and gently palpated for tenderness, rigidity, or abnormal masses.
The pelvis is checked for stability and pain. The extremities (arms and legs) are inspected for deformities, swelling, open wounds, or altered sensation and movement. Pulses are checked in all limbs. The patient’s back and spine are carefully examined, looking for injuries and palpating for tenderness or step-offs along the vertebrae.
Continuous Reassessment
A secondary assessment is not a singular event but part of an ongoing process in patient care. Continuous reassessment involves regularly monitoring the patient’s condition to detect changes, whether improvements or deteriorations. This includes re-evaluating vital signs, observing the patient’s level of consciousness, and checking the status of their primary complaint.
The effectiveness of interventions provided is also continuously assessed. The frequency of reassessments varies based on patient stability; for unstable patients, reassessment may occur every 5 to 15 minutes, while stable patients might be reassessed every 2 to 4 hours. This dynamic monitoring ensures care plans can be adjusted promptly to meet evolving needs.