Week 6

Context

On completion of steps ABCD, we then move onto E, which stands for Exposure. In this part of the assessment we are looking for any clues to explain the patient’s condition. In order to do so in a systematic way, we use a secondary survey. Remember - throughout the A-E Assessment if the patient's condition deteriorates or they become unstable, you need to escalate. If you need to leave the patient at any time to get help, you must reassess the airway again before continuing.

Content

Privacy and Dignity

Before commencing the examination of the patient, you need to consider the patient’s privacy and dignity (see Dignity, Privacy And Confidentiality section)

The assessment:

Throughout the assessment, you are observing and feeling for any of the following:

signs of trauma
bleeding
skin rashes
swelling
leakage of bodily fluids
needle marks
wounds

Whist examining the patient, maintain communication at all times, observe the patients reaction to the examination, looking for signs of pain and discomfort. “On the floor and four more” is a term frequently utilised in trauma and is a great term to help you remember the steps involved in the secondary survey. On the floor means that firstly you need to look on the floor for any signs of bodily fluids, which would be an obvious sign. Once you have checked the floor, move onto the patient, splitting the assessment into the following sections:

Head
Thoracic cavity
Abdominal cavity
Long bones

Head

Firstly just observe the patients face and head for any abnormalities.
Check the ears and nose for signs of any fluid, any straw coloured fluid leaking from these orifices may be indicative of a basal skull fracture.
You would have already checked the patient’s pupils in D, but observe the eyes for any swelling, rashes or signs of trauma.
Check the patients lips for signs of swelling, which may be indicative or an allergic reaction or anaphylaxis.
Are there any signs of cyanosis on the patient’s lips?

Thoracic region

Note the expansion of the chest, look to see if it is symmetrical, an asymmetrical chest movement is indicative of rib fractures, pneumothorax and a range of respiratory conditions
Is there any shift of the midline, which may indicate a tension pneumothroax
Check for any wounds, drains or penetrating objects in the thoracic region, that you may not have noticed when completing the A and B section of your assessment

Abdominal Cavity

Observe for any signs of surgery or injury
Are there any wounds, inspect the wounds for signs of inflammation?
Is there any bruising, does the patient show any signs of pain?
Is the abdomen distended?

Long Bones/Extremities

Check the legs for any signs of fractures or trauma, swelling, discolouration
Compare the legs for size and colour
Is the patient wearing anti-embolic stockings?

You have now completed the front part of the body, to examine the back, you will need to find some help to log roll the patient. Once ready, examine the back for any signs of tenderness, deformity, wounds or bodily fluids.

On completion of the secondary survey, you need to then find out about any past medical history. Use the AMPLE acronym:

Allergies – does the patient know of any allergies they have, check the notes, does the patient have a wristband which indicates that they have an allergy
Medications – take note of the patient’s mediations, have a look for a drug chart, is there anything that could contribute to this deterioration on their drug chart
Previous Medical History/surgical history – check the patient’s notes and ask the patient questions if they are able to answer. Consider closed questions for a patient that is short of breath.
Last Meal – if the patient needs surgical intervention, this is an important fact to know
Event/Environment surrounding any injury, what happened, is there an event history?

Gather together all of your information. Ensure you have examined any observation chart, fluid balance charts and any other information available.At this point, you need to make an action plan. Do you escalate? Do you continue to monitor for signs of deterioration. If in doubt – ESCALATE!

Remember when escalating to use SBAR.

References and Further Reading

Jevon, P. (2010) Assessment of critically ill patients: the ABCDE approach British Journal of Healthcare Assistants 4.8 (August 2010): 404-407.

Resuscitation Council (2005) A systematic approach to the acutely ill patient [WWW] http://www.resus.org.uk/pages/alsabcde.htm