Primary Survey in Nursing

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Questions and Answers

What is the primary purpose of a primary survey?

To rapidly identify potential or actual life threats that require immediate intervention

What is the core physical assessment arranged in order of performance during a primary survey?

The primary survey is arranged in order of performance, as identified by Douglas et al. (2016)

What are the five areas of nursing assessment in breathing?

Respiratory rate, depth of respirations, patterns of respiration, lung sounds, oxygenation

What is the first step in the primary survey?

The airway Signup and view all the answers

What does the Disability part of the primary assessment focus on?

Pain Signup and view all the answers

What is the importance of back blow maneuvers in airway management?

To relieve sudden upper airway obstruction, especially in pediatric patients Signup and view all the answers

What is the definition of pain according to Margo McCaffery?

Pain is whatever the experiencing person says it is, existing whenever he says it does Signup and view all the answers

What is the primary goal of airway management?

To maintain a patent airway Signup and view all the answers

What is the purpose of primary assessment?

To identify immediate life-threatening alterations in function Signup and view all the answers

Why is the primary survey critical in patient care?

To identify and address potential or actual life threats that require immediate intervention Signup and view all the answers

What do the first three stages of the clinical reasoning cycle rely on?

Primary assessment Signup and view all the answers

Why is it essential to believe the patient's report of pain?

Because pain is subjective and only the patient can accurately report their experience Signup and view all the answers

What is assessed in the Exposure part of the primary assessment?

The patient's exposure to the environment Signup and view all the answers

What is the primary focus of the Circulation part of the primary assessment?

The patient's circulatory system Signup and view all the answers

What is the primary purpose of clinical assessment in patient care?

To identify abnormal findings, detect clinical deterioration, and feed information into the clinical reasoning cycle to plan care. Signup and view all the answers

What is the consequence of failing to conduct a thorough clinical assessment?

Patients are put at risk. Signup and view all the answers

What is the relationship between the primary survey and the Clinical Reasoning Cycle?

The primary survey feeds information into the Clinical Reasoning Cycle to plan care. Signup and view all the answers

What is the significance of vital signs in the primary survey?

Vital signs are an essential component of the primary survey, providing valuable information about the patient's condition. Signup and view all the answers

What is the primary survey, and what is its role in patient assessment?

The primary survey is a structured approach to clinical assessment, forming the basis of clinical assessment in every patient encounter. Signup and view all the answers

What is the purpose of the Clinical Reasoning Cycle in patient care?

To plan care. Signup and view all the answers

What is the significance of a structured nursing assessment in patient care?

It is essential to identify abnormal findings, detect clinical deterioration, and feed information into the clinical reasoning cycle to plan care. Signup and view all the answers

What is the recommended reading for further learning about the primary survey?

Chapter 16: Vital signs: Using a primary survey approach for patient assessment in Potter & Perry's Fundamentals of Nursing - ANZ edition. Signup and view all the answers

What observation is made about a person's stated age and apparent age in a general survey?

The person's stated age should be congruent with their apparent age. Signup and view all the answers

What is an abnormal finding in the general appearance of a person during a general survey?

Visible disabilities or anomalies, facial asymmetry, or distinctive markings. Signup and view all the answers

What is a normal finding in terms of body fat distribution during a general survey?

Body fat is fairly evenly distributed, with different types of body shapes. Signup and view all the answers

What posture is expected in a person during a general survey?

Erect posture with arms and legs in proportion to body height. Signup and view all the answers

What is a normal finding in terms of motor activity during a general survey?

Movement and gait are smooth and effortless, with controlled purposeful movement. Signup and view all the answers

What is an abnormal finding in terms of body conformation during a general survey?

Posture is slumped, humpbacked, or kyphotic. Signup and view all the answers

What is an abnormal finding in terms of body shape and size during a general survey?

Body shape is uneven, or body mass index (BMI) is underweight, overweight, or obese. Signup and view all the answers

What is the significance of assessing body symmetry during a general survey?

It helps identify any visible disabilities or anomalies that may indicate underlying health issues. Signup and view all the answers

What is a normal mental status and cognitive function in a patient?

Appear awake and alert, orientated to person, place and date/time, with normal memory and function. Signup and view all the answers

What is an abnormal facial expression in a patient?

Lack of expression, apathy, unchanging or flat facial expression, inappropriate facial expression, tremors, or tics. Signup and view all the answers

What is a normal body odour and breath?

Reasonably odour free, with some dependence on diet. Signup and view all the answers

What is an abnormal mood and manner in a patient?

Uncooperative, hostile, tearful, unusual elation, mood swings, flat effect or mood, euphoria. Signup and view all the answers

What is a normal dress, grooming, and personal hygiene in a patient?

Presents clean and neatly dressed, with appropriate clothing for the weather. Signup and view all the answers

What is an abnormal speech and communication in a patient?

Speech that is slow, slurred, mumbled, or not understandable. Signup and view all the answers

What is a normal body shape and size in a patient?

Not specified in the provided content, but a normal body shape and size would typically be proportionate and symmetrical. Signup and view all the answers

What is an abnormal posture and motor activity in a patient?

Not specified in the provided content, but an abnormal posture and motor activity may include unusual or abnormal movements, rigidity, or tremors. Signup and view all the answers

What is the primary difference between subjective and objective assessment data in a health assessment?

Subjective assessment data is obtained from the patient or carer, while objective assessment data is physical data observed through senses, measurements, or direct observation. Signup and view all the answers

What is an example of abnormal assessment data in a patient's vital signs?

A heart rate outside the normal range (e.g., 100 bpm or higher), or a blood pressure reading above 140/90 mmHg. Signup and view all the answers

What aspects of a patient's psychological status are typically assessed during a general survey?

Level of consciousness, mood, and emotional state. Signup and view all the answers

What is the significance of body odour and breath in a general survey?

Unusual or unpleasant body odour and breath can indicate underlying health issues, such as diabetes or liver disease. Signup and view all the answers

What does a patient's posture and motor activity reveal during a general survey?

Musculoskeletal function, mobility, and potential neurological issues. Signup and view all the answers

What information can be gained from assessing a patient's body shape and size?

Potential health risks, such as obesity or malnutrition, and potential underlying conditions, such as Cushing's syndrome. Signup and view all the answers

What is the significance of assessing body symmetry in a general survey?

To identify potential musculoskeletal or neurological issues, such as scoliosis or hemiparesis. Signup and view all the answers

What is the relationship between acute patient deterioration and health assessment?

Acute patient deterioration is a critical aspect of health assessment, as it involves identifying physiological changes and acute changes in cognition and mental state. Signup and view all the answers

What are the key elements of therapeutic communication in healthcare, and how do they promote physical and emotional well-being in patients?

The key elements of therapeutic communication are active listening, empathy, non-judgmental attitude, open-ended questions, clarification, and validation. These elements promote physical and emotional well-being by fostering trust, respect, and understanding between healthcare providers and patients. Signup and view all the answers

What are the key components of clinical handover protocols, and how do they ensure continuity of care?

The key components of clinical handover protocols include clear and concise communication, accurate and up-to-date information, standardized documentation, and face-to-face or verbal handover. These components ensure continuity of care by reducing errors and omissions, and enhancing collaboration among healthcare providers. Signup and view all the answers

What are the key principles of person-centered care approaches, and how do they improve patient outcomes and satisfaction?

The key principles of person-centered care approaches include patient autonomy and participation, holistic care, personalized care plans, and collaboration with patients and families. These principles improve patient outcomes and satisfaction by prioritizing individual needs, values, and preferences. Signup and view all the answers

What is the significance of nursing standards and practices, and how do they impact the quality of patient care?

Nursing standards and practices outline the expected level of performance and quality of care provided by nurses. They impact the quality of patient care by ensuring consistency, safety, and excellence in nursing practice. Signup and view all the answers

How does therapeutic communication facilitate clinical decision-making and patient-centered care?

Therapeutic communication facilitates clinical decision-making and patient-centered care by promoting active listening, empathy, and understanding, which enable healthcare providers to make informed decisions that align with patients' needs and preferences. Signup and view all the answers

What is the relationship between clinical handover protocols and patient safety, and how do they reduce errors and omissions?

Clinical handover protocols reduce errors and omissions by ensuring accurate and up-to-date information transfer between healthcare providers, thus ensuring patient safety and continuity of care. Signup and view all the answers

How do person-centered care approaches promote patient autonomy and participation in healthcare decision-making?

Person-centered care approaches promote patient autonomy and participation by prioritizing individual needs, values, and preferences, and involving patients in healthcare decision-making processes. Signup and view all the answers

What is the significance of nursing standards and practices in ensuring consistency and excellence in nursing care?

Nursing standards and practices ensure consistency and excellence in nursing care by outlining the expected level of performance and quality of care, promoting high-quality, patient-centered care. Signup and view all the answers

Study Notes

Primary Survey

The primary survey rapidly identifies potential or actual life threats that require immediate intervention.
It is a core physical assessment arranged in a specific order of performance.

Airway

The airway is an essential part of the primary survey.
It involves assessing the patient's airway management.

Breathing

Breathing assessment is defined by five areas of nursing assessment:
- Respiratory rate
- Depth of respirations
- Patterns of respiration
- Lung sounds
- Oxygenation

Circulation

Circulation is an important part of the primary survey.

Disability

Disability assessment involves evaluating the patient's level of consciousness using the AVPU scale.
The AVPU scale assesses the patient's Alertness, Voice, Pain, and Unresponsiveness.

Disability - Pain

Pain is a subjective experience and can only be truly understood by the patient experiencing it.
The healthcare professional should assess for pain in a manner appropriate for the patient and believe their report of pain.
Pain assessment is an essential part of the primary survey.

Exposure

Exposure involves a thorough head-to-toe examination of the patient.
It is an essential part of the primary survey.

Summary

The primary survey identifies immediate life-threatening alterations in function.
It forms the basis of clinical assessment for all patients.
The primary survey feeds information into the first three stages of the clinical reasoning cycle.

General Survey: Physical Status

The general survey involves assessing the person's overall appearance, including their age, physical characteristics, and overall health state.
A person's stated age should match their apparent age.
A person's general appearance should be symmetrical, with no obvious deformity or disabilities.
Body fat should be fairly evenly distributed, with no visible signs of disease-related weight distribution issues.
Posture should be erect, with arms and legs in proportion to body height.
Motor activity should be smooth and effortless, with controlled purposeful movement.
Body and breath odour should be reasonably odour-free, dependent on diet.

General Survey: Psychological Status

A person's mental status and cognitive function should be normal, with an alert and awake appearance.
The person should be orientated to person, place, and date/time.
Facial expression should be appropriate for the circumstances and change naturally.
Dress, grooming, and personal hygiene should be clean and neat.
Mood and manner should be cooperative and pleasant.
Speech and communication should be clear and understandable.

Assessment Data

Objective assessment data involves physical data observed using our senses.
Subjective assessment data involves information obtained from the patient or carer.
Abnormal assessment data deviates from what is normal, e.g., outside normal vital sign ranges.

Acute Patient Deterioration

Acute deterioration involves physiological changes as well as acute changes in cognition and mental state.

Therapeutic Communication

Purposeful and goal-directed interaction between healthcare provider and patient to promote physical and emotional well-being
Involves active listening, empathy, non-judgmental attitude, open-ended questions, and clarification and validation
Respects patient autonomy, is culturally sensitive, and individualized
Improves patient outcomes, increases patient satisfaction, and enhances healthcare provider-patient relationships

Clinical Handover Protocols

Standardized process for transferring patient care information between healthcare providers
Ensures clear and concise communication, accurate and up-to-date information, and standardized documentation
Conducted through face-to-face or verbal handover
Ensures continuity of care, reduces errors and omissions, improves patient safety, and enhances collaboration

Person-centered Care Approaches

Focuses on individual patient's unique needs, values, and preferences
Involves patient autonomy and participation, holistic care, personalized care plans, and collaboration with patient and family
Improves patient outcomes, increases patient satisfaction, and enhances patient-provider relationships

Nursing Standards and Practices

Guidelines and principles outlining expected level of performance and quality of care
Includes professional standards (e.g., ANA, ICN), evidence-based practice, continuous quality improvement, and patient-centered care
Ensures high-quality care, enhances patient safety, promotes professional accountability, and guides nursing practice and decision-making

Clinical Reasoning and Decision Making

Process of critical thinking and problem-solving used to make informed decisions about patient care
Involves critical thinking and analysis, evidence-based practice, clinical judgment, and reflective practice
Ensures high-quality care, improves patient outcomes, enhances patient safety, and promotes professional development and growth

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Description

Identify the purpose and components of a primary survey in nursing, which is a rapid assessment to identify life-threatening conditions. Learn about the core physical assessment performed in the primary survey.