WEEK 3 NURSING - PRIMARY, SECONDARY AND FOCUSED ASSESSMENT

Question 1

purpose of primary assessment

Answer 1

• A primary assessment is a systematic approach that
  includes all body systems.
• Quickly identifies the deteriorating and critically ill patient and intervene rapidly
• Main focus is to stabilise the patient before moving on to
  secondary and focused assessments that can assist in
  diagnosis and treatment.

Question 2

what is a primary assessment

Answer 2

• Rapid assessment used to identify life threatening conditions to allow for prompt management.
• Performed shortly after the person is admitted to a
  healthcare service or when you first enter their room.
  -Enables care to be prioritised based on immediate patient requirements based on their current state of health.
• Help recognise when more senior nursing and medical
  help is required.

Question 3

components of primary assessment

Answer 3

Danger
Response
Send for help
Airway and c-spine
Breathing
Circulation
Disability
Exposure and environment

Question 4

danger

Answer 4

• Identify any dangers to patient and self or other healthcare professionals involved in the situation.
• Dangers can include aggressive bystanders, blood
  and bodily fluids, sharps, spills on the floor.
• Stop and remove the dangers if safe to do so before
  attempting to help the patient. Do not place yourself
  at danger.

Question 5

response

Answer 5

• Can you elicit any verbal or motor response?
• Do this by asking the patient to open their eyes or touch and squeeze their shoulder.
• Failure to respond is a clear indicator of serious illness.
• Very little time should be spent on this. If there is no
  response from your patient you need to quickly move
  on to the next step.

Question 6

send for help

Answer 6

• If you cannot elicit a response OR there is danger call
  for help!
• Press the emergency call button, shout for help or dial
  the hospital emergency number
• Never leave an unconscious patient alone, always
  stay with them until help arrives.

Question 7

airway and c-spine

Answer 7

• Ensure airway is patent
• Perform a head tilt and chin lift manoeuvre to open
  the airways.
• Assess for airway compromise – consider using
  suction to remove any fluid or Magill’s forceps to
  remove solid material.
• Think about potential spinal cord injury and manage
  as required
• Use a jaw-thrust manoeuvre if you suspect a spinal
  injury.

Question 8

breathing

Answer 8

• Assess for effective respirations
• Assess air entry to the lungs
• Assess skin and mucous membrane colour
• Check chest wall movement, expansion and
  symmetry

Question 9

circulation

Answer 9

• Check for signs of impending cardiovascular collapse
• Assess central pulses
• Assess pulse rate and quality
• Assess skin colour and warmth
• Assess capillary refill
• Assess/manage internal and external haemorrhage
• Auscultate to hear the S1 and S2 heart sounds

Question 10

disability

Answer 10

• Assessment of central nervous system function
• AVPU (Alert, responsive to Verbal stimulus,
  responsive to Painful stimulus, Unconscious and
  unresponsive)
• Check pupil response (PEARL) and consensual
  reaction. Pupils Equal And Reactive to Light
• Limb assessment for strength and sensation
• Ask about pain
• Check for reversible causes of reduced consciousness:
  – Medications (i.e. opioids, benzodiazepines, hypnotics)
  – Blood glucose level
  – Haemorrhagic shock and hypotension
  – Overdose
  – Anaphylaxis

Question 11

environment and exposure

Answer 11

• Remove clothing to expose patient as required
• Maintain body temperature during exposure
• Assess for signs of injury, trauma or illness (i.e.
  anaphylaxis)
• Assessment for clues to the cause of patient condition
• Ensure emergency equipment is available at
  bedspace:

Question 12

components of secondary assessment

Answer 12

• health history interview
• physical exam
• vital signs assessment

Question 13

health history interview

Answer 13

1. Biographical data
2. Reason for seeking care
3. Perception of present state of health
4. Past health and medical history
5. Family history
6. General overall health and wellbeing
7. Health and lifestyle management

Question 14

physical exam

Answer 14

• Head-to-toe or systems assessment of body systems:
  – General survey
  – Head and neck
  – Neurological
  – Cardiovascular
  – Respiratory
  – Gastrointestinal
  – Genitourinary
  – Skin and extremities
  – Endocrine
  – Posterior

Question 15

focused assessment

Answer 15

• Thorough assessment of a particular clinical manifestation
  related to a particular body system.
• Completed throughout each shift and at handover to
  review patient progress and detect deterioration.
• Using the skills of inspection, auscultation, palpation and
  percussion.