Assessment: Secondary Assessment

  1. Perform hand hygiene and apply clean gloves.
  2. Verify the patient's identity in accordance with institutional policy.
  3. Maintain cervical spine alignment for trauma patients as initiated in the primary assessment.
  4. Remove all clothing to facilitate a complete patient assessment. Cover the patient to preserve the body temperature.
  5. Obtain blood pressure, pulse, and respirations. Temperature determination may be deferred until the secondary assessment is completed, but it should be performed as quickly as possible in the very old, in the very young, and in those with potential hypothermia or hyperthermia.
  6. Initiate cardiac and pulse oximetry monitoring.
  7. If the patient is conscious, obtain information about painful areas by instructing him or her to report any tenderness elicited by palpation. Obtain a brief history of the mechanism of the injury; the history of the present illness; any chronic diseases, allergies, or pertinent immunizations; current medications (prescription, over the counter, and herbal); and any recent use of alcohol or illicit drugs.
  8. Inspect the head and face for wounds, deformities, discolorations, or bloody/serous drainage from the nose or ears. Palpate the entire head and face for wounds, deformities, or tenderness. In the conscious and cooperative patient, evaluate extraocular movements, gross vision, and dental occlusion. Note any unusual odors, for example, gasoline, fruity breath, or ethanol.
  9. If necessary, remove the anterior portion of the cervical collar while another person maintains manual immobilization of the head and neck. 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). Gently palpate the posterior neck from the base of the skull to the upper back for wounds, deformities, tenderness, or muscle spasm.
  10. 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. Auscultate breath sounds to determine whether they are present and equal bilaterally, and note any abnormal sounds, such as crackles and wheezes. Auscultate heart sounds to determine whether they are clear or muffled.
  11. Inspect the abdomen for wounds, discolorations, or distention. Auscultate all quadrants for the presence of bowel sounds. Gently palpate the abdomen for tenderness, guarding, rigidity, or masses (palpate the areas that are known to be painful last).
  12. Inspect the pelvic area and genitalia for wounds, deformities, discolorations, or bleeding from the urinary meatus, vagina, or rectum. Palpate for pelvic tenderness, crepitus, or instability by gently pressing in on the anterosuperior iliac crests bilaterally and pushing down on the pubic symphysis. Palpate femoral pulses for presence and equality.
  13. Inspect all extremities for wounds, deformities, or discolorations. Palpate all extremities for tenderness, deformities, muscle spasm, and distal pulses. If the patient is conscious, determine gross motor and sensory function by having the patient wiggle the toes and fingers and asking whether he or she can feel your touch.
  14. 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 if possible. In some patients, it may be necessary to roll the patient to both sides to assess the posterior surfaces adequately. Inspect the posterior surfaces for wounds, deformities, or discolorations. Palpate all posterior surfaces for wounds, deformities, or muscle spasm.
  15. In male trauma patients, the physician or advanced practice nurse performs a rectal examination to assess sphincter tone, prostate position, and stool for occult blood. In female trauma patients, the physician or advanced practice nurse performs a rectal examination to assess sphincter tone and stool for occult blood.
  16. Discard supplies, remove gloves, and perform hand hygiene.
  17. Document the procedure in the patient's record.
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