Primary Survey in Nursing

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

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

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

The airway

Pain

To relieve sudden upper airway obstruction, especially in pediatric patients

Pain is whatever the experiencing person says it is, existing whenever he says it does

To maintain a patent airway

To identify immediate life-threatening alterations in function

To identify and address potential or actual life threats that require immediate intervention

Primary assessment

Because pain is subjective and only the patient can accurately report their experience

The patient's exposure to the environment

The patient's circulatory system

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

Patients are put at risk.

The primary survey feeds information into the Clinical Reasoning Cycle to plan care.

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

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

To plan care.

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

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

The person's stated age should be congruent with their apparent age.

Visible disabilities or anomalies, facial asymmetry, or distinctive markings.

Body fat is fairly evenly distributed, with different types of body shapes.

Erect posture with arms and legs in proportion to body height.

Movement and gait are smooth and effortless, with controlled purposeful movement.

Posture is slumped, humpbacked, or kyphotic.

Body shape is uneven, or body mass index (BMI) is underweight, overweight, or obese.

It helps identify any visible disabilities or anomalies that may indicate underlying health issues.

Appear awake and alert, orientated to person, place and date/time, with normal memory and function.

Lack of expression, apathy, unchanging or flat facial expression, inappropriate facial expression, tremors, or tics.

Reasonably odour free, with some dependence on diet.

Uncooperative, hostile, tearful, unusual elation, mood swings, flat effect or mood, euphoria.

Presents clean and neatly dressed, with appropriate clothing for the weather.

Speech that is slow, slurred, mumbled, or not understandable.

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

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

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

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

Level of consciousness, mood, and emotional state.

Unusual or unpleasant body odour and breath can indicate underlying health issues, such as diabetes or liver disease.

Musculoskeletal function, mobility, and potential neurological issues.

Potential health risks, such as obesity or malnutrition, and potential underlying conditions, such as Cushing's syndrome.

To identify potential musculoskeletal or neurological issues, such as scoliosis or hemiparesis.

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

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.

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.

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.

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.

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.

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.

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

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.