NURSING IV

THE SECONDARY SURVEY IN BASIC CARDIAC LIFE SUPPORT

(BCLS)

CREATED BY:
A9-D
GROUP 1

BACHELOR OF NURSING DEGREE

WIRA MEDIKA PPNI BALI INSTITUTE OF HEALTH SCIENCES
DENPASAR
2018/2019
CHAPTER I
INTRODUCTION

A. Problem Background
Cardiopulmonary arrest is usually the result of a cardiac dysrhythmia. The majority of
adults (80% to 90%) with sudden, non-traumatic cardiac arrest are found to be in
ventricular tachy-cardia (VT) when an initial electrocardiographic rhythm strip is
obtained. When ventricular fibrillation (VF) occurs outside the hospital, it most
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 commonly results from chronic myocardial ischemia with electrical instability, rather than
acute myocardial infarction,
There are many circumstances that would cause death within a short time, but it all
ends up at one end of which is failure of oxygenation of cells, especially brain and heart.
The work done untu sustain life when people develop a life-threatening objec known as
"Live Aid" (Life Support).
Basic life support (BLS) is the provision of care to an unresponsive patient. The
mainstay of BLS is cardiopulmonary resuscitation, or CPR. Immediate bystander CPR
given to a witnessed cardiac arrest doubles the chances of survival. It is important that
those who may be present at the scene of a cardiac arrest, particularly lay bystanders,
should have learnt the appropriate resuscitation skills and be able to put them into
practice. Simplification of the BLS sequence continues to be a feature of these guidelines,
but, in addition, there is now advice on who should be taught what skills, particularly
chest-compression-only or chest compression and ventilation. Within this advice,
allowance has been made for the rescuer who is unable or unwilling to perform rescue
breathing, and for those who are untrained and receive telephone advice from the
ambulance service.
The next section takes you step-by-step through the procedures needed to perform
survey the scene – the basic skill needed to save life in the event of cardiac arrest.
Besides, in the next chapter will be explained how to do step by step in survey the scene.

B. The Problem
1. What is the definition of Secondary Survey in Basic Cardiac Life Support (BCLS)?
2. What are the general procedures of Secondary Survey?
3. What are the the considerations in doing the secondary survey?

C. The Target
Bcls training purposes and competencies to provide basic understanding to the
participants to be able to provide basic life support in accordance with established
standards of competence.

D. The Benefit
1. To recognize the definition of Secondary Survey in Basic Cardiac Life Support
(BCLS)
2. To recognize the general procedure of Secondary Survey

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 3. To recognize the considerations in doing secondary survey

E. Writing Method
Writing method used in compiling this handing out is the descriptive method
qualitative, where data obtained from bibliography media by literature is supporter
supporting studied problem.

CHAPTER II
THE BODY

A. The Definition of Secondary Survey

The secondary survey (detailed or focused assessment) is a systematic head-
to-toe examination of every part of the patient’s body, including assessing the vital
signs and obtaining a patient history. Secondary survey is only done when the patient
was stable when ABC during the secondary survey the patient's condition deteriorates
then we must go back to repeat the primary survey. All procedures are performed
should be recorded properly. Examination from head to toe (head-to-toe examination)
conducted by a major concern. The call for EMS assistance is often the patient's entry
point into the medical care system. It is important that EMS personnel conduct a
systematic secondary survey to ensure medical or traumatic conditions are identified
and the patient’s baseline is established. This will permit identification of changes in
the patient’s condition. For example, you might find possible broken bones, minor
bleeding, or a specific medical condition such as epilepsy.

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1. The Purpose
The purpose of a secondary assessment (composed of a head-to-toe, history
and vitals) is to continually monitor the victims condition and find any non-life
threatening conditions requiring treatment. A secondary assessment should be
done for any victim requiring ambulance intervention, or if there is a concern that
the victims condition may deteriorate. In some cases, you may want to do an
shortened secondary survey - use your best judgment.

2. The Head to Toe Use For

The Head-to-toe assessment is a technique used by lay rescuers, first
responders, and ambulance personnel to identify an injury or illness or determine
the extent of an injury or illness.
It is used on victims who meet the following criteria:
a. Victim of trauma injuries (except minor injuries affecting peripheral areas)
b. Unconscious victims
c. Victims with very reduced level of consciousness
If a victim is found unconscious, and no history is available, you should
initially assume that the unconsciousness is caused by trauma, and where possible
immobilize the spine, until you can establish an alternative cause.
The secondary assessment should be performed on all the victim meeting the
criteria (especially trauma) regardless of gender of rescuer or victim. However,
you should be sensitive to gender issues here (as with all aspects of first aid), and
if performing a full body check on a member of the opposite sex, it is advisable to
ensure there is an observer present, for your own protection. In an emergency
however, victim care always takes priority.

3. Priority of ABC
The head-to-toe should be completed after the primary survey, so you are already
confident in the victim having a patent airway, breathing satisfactorily and with a
circulation. You should always make ABCs a priority when dealing with victims
who are appropriate for a secondary survey. In the case of trauma victims, where
the victim is conscious and able to talk, keep talking to them throughout. This not
only acts to reassure them and inform them what you’re doing, but will assure you
that they have a patent airway and are breathing.
For unconscious victims, if you are on your own, check the ABCs between
checking every body area, or if you are with another competent person, make sure
they check ABCs continuously while you perform the secondary assessment.
4. The Head to toe Looked For

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 The head-to-toe is a detailed examination where you should look for abnormality.
This can take the form of asymmetry; deformity; bruising; point tenderness
(wincing or guarding - don’t necessarily expect them to tell you); minor bleeding;
and medic alert bracelets, anklets, or necklaces. It is important to remember that
some people naturally have unusual body conformation, so be sensitive about this,
but don’t be afraid to ask the conscious victim or relatives if this is normal for
them. It is always worth looking for symmetry - if it is the same both sides, the
chances are, it’s normal.

B. The General of Secondary Survey do

1. Personal protective equipment should be utilized as required
2. Body substance isolation techniques should be utilized as required
3. A secondary survey should NOT be done on the scene if a life threatening illness
or injury has been identified and it cannot be immediately corrected
a. Performing the secondary survey in this situation is unlikely to yield any
conditions that will significantly improve the patient’s condition
b. These patients should have their secondary survey carried out en route if
possible
4. Assess the patient's airway - Is the patient's airway open? If the patient is
unresponsive stabilize the head and neck and use the jaw-thrust maneuver to
ensure an open airway. If you do not suspect a spine injury use the head tilt, chin
lift maneuver.
5. Assess the patients breathing - Is the patient breathing adequately? With the
airway open, place your ear over the patient's nose and mouth and watch for
chest movement, note symmetry or lack of symmetry in chest movement. Listen
and feel for the presence of exhaled air. Listen to the quality of the breath sounds.
Sporadic respirations are called agonal respirations and occur just prior to death.
6. Assess the patient's circulation (pulse and bleeding) - Does the patient have an
adequate pulse. Is there serious bleeding. Did the patient lose a large quantity of
blood prior to your arrival?
a. If the patient is not breathing check the pulse at the neck (carotid).
b. If the patient is breathing you can check the carotid or the pulse at the wrist
(radial)

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 c. If you document the presence of a carotid pulse but the radial pulse is absent
this may represent a shock situation. A rapid or weak pulse may also represent
a shock situation.
d. Although any uncontrolled bleeding may become life threatening, you are
only concerned with profuse bleeding during the initial assessment
e. Blood that is bright red and spurting may be coming from an artery
f. Flowing blood that is darker in color typically reflects a venous origin
g. Your concern is for the total amount of blood lost, not just how fast or slow the
bleeding is.
h. Assessment of circulation also includes checking skin signs - color,
temperature, and moisture. Abnormal findings such as pale cool , moist skin
could be indicative of shock
If any of these interventions prevents performance of a secondary survey,
the reason(s) should be documented on the patient care report

7. Perform an organized head-to-toe assessment

Head to Toe Examination of a Trauma Patient with Significant MOI - The
physical examination of the patient should take no more than two to three
minutes
a. Head – Check the scalp for cuts, bruises, swellings, and other signs of injury.
Examine the skull for deformities, depressions, and other signs of injury.
Inspect the eyelids/eyes for impaled objects or other injury. Determine pupil
size, equality, and reactions to light. Note the color of the inner of the inner
surface of the eyelids. Look for blood, clear fluids, or bloody fluids in the nose
and ears. Examine the mouth for airway obstructions, blood, and any odd
odors Sores on the scalp.
b. Neck - Examine the patient for point tenderness or deformity of the cervical
spine. Any tenderness or deformity should be an indication of a possible spine
injury. If the patient's C-spine has not been immobilized immobilize now prior
to moving on with the rest of the exam. Check to see if the patient is a neck
breather, check for tracheal deviation
c. Chest - Examine the chest for cuts, bruises, penetrations, and impaled objects.
Check for fractures. Note chest movements a look for equal expansion.

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 d. Abdomen - Examine the abdomen for cuts bruises, penetrations, and impaled
objects. Feel the abdomen for tenderness. Gently press on the abdomen with
the palm side of the fingers, noting any areas that are rigid, swollen, or painful.
Note if the pain is in one spot or generalized. Check by quadrants and
document any problems in a specific quadrant.
e. Lower Back - Feel for point tenderness, deformity, and other signs of injury
f. Pelvis - Feel the pelvis for injuries and possible fractures. After checking the
lower back, slide your hands from the small of the back to the lateral wings of
the pelvis. Press in and down at the same time noting the presence of pain and/
or deformity
g. Genital Region - Look for wetness caused by incontinence or bleeding or
impaled objects. In male patients check for priapism (persistent erection of the
penis). This is an important indication of spinal injury
h. Lower Extremities - Examine for deformities, swellings, bleedings,
discolorations, bone protrusions and obvious fractures. Check for a distal
pulse. The most useful is the posterior tibial pulse which is felt behind the
medial ankle. If a patient is wearing boots and has indications of a crush injury
do not remove them. Check the feet for motor function and sensation.
i. Upper Extremities - Examine for deformities, swellings, bleedings,
discolorations, bone protrusions and obvious fractures. Check for the radial
pulse (wrist). In children check for capillary refill. Check for motor function
and strength.
8. Life-threatening conditions not identified in the primary survey but identified in
the secondary survey should be treated immediately
9. Life-threatening conditions identified and treated in the primary survey should be
reassessed in the secondary survey
10. Load and go criteria should be considered throughout the entire secondary survey
11. Reassure the patient and keep him/her informed about treatment(s)
12. Obtain a pertinent, focused history from the patient, family, bystanders, and first
response agency (if applicable)
13. Consider alternate sources of medical identification (e.g. Medic-Alert) if
available
14. Obtain and record
a. level of consciousness
b. pulse
c. espiratory rate
d. blood pressure
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 e. auscultation of the lungs (if within scope of practice)
f. assessment of skin
g. assessment of pupils
h. pulse oximeter reading, if indicated (if within scope of practice)
i. glucometer readings, if indicated (if within scope of practice)

C. THE CONSIDERATIONS
Patient History
1. The goal is to facilitate rapid identification of patient problem(s) and establish which
problem(s) require.
2. Immediate care in the field circumstances surrounding an emergency response may
make it difficult to obtain all relevant historical information.
3. The patient history includes any information relating to the current complaint or
condition, as well as past medical problems that could be related. EMS personnel
must make every effort to obtain a relevant, detailed patient history on every
Acronym to obtain a patient's history
S - Signs/symptoms
A - Allergies
M - Medications (drugs taken previously)
P - Pertinent past medical history
L - Last oral intake
E - Events leading to the illness or injury(the environment associated with gravity)
4. Patient and document this information on the patient care report
a. Patient identifiers: patient name, age, sex, date of birth, and personal health
information number
b. Chief complaint: main reason patient called for assistance
c. Mechanism of injury: this includes a scene assessment
d. History of present illness or injurythis includes a number of qualifying factors
1) location
2) quality
3) intensity
4) quantity
5) sequence of events
6) circumstances surrounding the onset of first symptoms
7) aggravating and alleviating factors
8) associated symptoms
9) attempts to relieve symptoms
10) pregnancy
e. Relevant past medical history
1) underlying medical problems
2) name of primary care doctor
3) name of clinic or hospital usually attended
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 4) Health Care Directives
f. Medications
1) include names and doses
2) confirm whether medications have been taken and their effect
3) identify who gave or assisted the patient to take or administer any medications
g. Allergies
1) past reactions
2) note any Medic-Alert identification
h. Observations
1) what was observed at the scene
2) what was done to and for the patient, particularly
a) extrication
b) intervention(s) or treatment(s)
i. Medication administration or assistance, including dose, route, time of
administration, and change(s) in patient status.
j. Reasons for decisions made that impacted on patient care
1) load and go, environment, physician on scene taking patient care
responsibility
2) any unusual circumstances
3) violence, abuse, neglect
4) any other potentially pertinent information
5. Assessment of Vital Signs
a. Initial set of vital signs should be taken on every patient
b. If not taken, a reason should be documented in the patient care report
c. Repeat at regular intervals (5-15 min.) or when there is a change in the patient’s
status
d. If the patient’s condition is unstable more frequent assessments are required

Vital Signs Must Include

a. Respirations
1) Present or absent
2) Rate (document as breaths per minute)
3) Rhythm, regular or irregular (note any patterns)
4) Quality
a) Evidence of dyspnea should be noted
b) Shallow, labored, noisy (if possible, describe the sound)

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 c) Evidence of accessory muscle use or diaphragmatic breathing
d) If EMS personnel are trained to perform chest auscultation this should
be done in the primary survey and repeated in the secondary survey
e) Bilateral, comparative auscultation of the lungs should be done
anteriorly and posteriorly.
f) Note presence or absence of breath sounds
b. Pulse
1) Present or absent
2) Rate (document as beats per minute)
3) Rhythm : Regular or irregular (note any patterns)
4) Quality : strong, weak, absent

c. Blood Pressure
1) Measure systolic and diastolic pressures, if possible
2) When assessing a BP
a) Ensure the BP cuff size is correct
b) Palpate a pulse distal to the BP cuff
c) Rapidly inflate the BP cuff to approximately 30 mm Hg beyond the
pressure at which the pulse
d) Initially disappears
e) Place the stethoscope diaphragm over the site being utilized for
assessment
f) Deflate the BP cuff at a rate of approximately 2 mm Hg per second
g) Note the systolic and diastolic pressures
h) Fully deflate the BP cuff
i) Document the pressures as systolic / diastolic in mm Hg
j) If the assessment was done by palpation, record the pressure as systolic
/P
k) Document any difficulties in obtaining a blood pressure
3) Patient’s position when measured

d. Glasgow Coma Scale

1) Core each component and record it on the patient care report

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 2) Repeat the assessment at regular intervals (5-15 mins.) or when there is a
change in the patient’s status
3) The “AVPU” scale can be used as an alternate method to assess level of
consciousness during the primary survey, but a more formal assessment
using the Glasgow Coma Scale is required for the secondary survey.
4) Classify the patient by the AVPU scale :
a) A - Alert. The alert patient is will be awake, responsive, oriented, and
talking with you
b) V - Verbal. This is a patient who appears to be unresponsive at first,
but will respond to a loud verbal stimulus from you - Note that the
term verbal does not mean that the patient is answering your questions
or initiating a conversation. The patient may speak, grunt, groan, or
simply look at you
c) P - Painful. If the patient does not respond to verbal stimuli, he may
respond to painful stimuli such a sternal (breastbone) rub or a gentle
pinch to the shoulder
d) U - Unresponsive. If the patient does not respond to either painful or
verbal stimuli
Age-associated Vital Signs

Age Blood pressure Pulse Respiratory rate

Term Newborn (3 kg)
Age 12 hours 50-70 / 25-45
Age 96 hours 60-90 / 20-60
74 +/- 22 mmHg
Age 7 days 80-200 40-60
(Systolic BP)
96 +/- 20 mmHg
Age 42 days
(Systolic BP)
Infant (6 months old) 87-105 / 53-66 80-180
Toddler (2 years old) 95-105/53-66 80-180 24
Schoolage (7 years old) 97-112/57-71 60-160
Adolescent (15 years old) 112-128/66-80 60-160 12

Attention:
1. Note vital signs (in accordance with the primary survey)

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2. In the case of trauma, examination of each stage always starts with a question there:
DECAPBLS
D: Deformity
E: excoriation
C: Contusio
A: Abrasion
P: Penetration
B: bullae / Burn
L: laceration
S: Swelling / puffy
3. On the alleged fracture always begins with a question there: PIC
P: Pain
I: Instability
C: Crepitasi

CHAPTER III
CONCLUCTION

A. Conclusion
Secondary survey is only done when the patient was stable when ABC during the
secondary survey the patient's condition deteriorates then we must go back to repeat the
primary survey. All procedures are performed should be recorded properly. Examination
from head to toe (head-to-toe examination) conducted by a major concern. The secondary
assessment should be performed on all the victim meeting the criteria (especially trauma)
regardless of gender of rescuer or victim. The head-to-toe should be completed after the
primary survey, so you are already confident in the victim having a patent airway,
breathing satisfactorily and with a circulation. You should always make ABCs a priority
when dealing with victims who are appropriate for a secondary survey.

B. Advise
When the primary assessment is finished, the nurse (the rescuer) must have to do
the head to toe examination comprehensively and immediately note each injury or trauma
which found. Doing assessment in BCLS needs skills so complicated. Being a nurse must
have to increase the knowledge about BCLS continuously and balance between practice
and theory. A nurse need to assess the victim’s condition so detail due to the patient could
be conscious or unconscious. If the victim is unconscious, perhaps we don’t know how
far the injury in their body. In order to prevent more injury, nurse must assess clearly.

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 REFERENCE

Ely Hermansyah. 2011. Materi PPGD Dan Basic Life Support. http://proemergency-
ems.blogspot.com/2008/12/basic-trauma-life-support-for-nurse.html. (accessed
June 19th 2017)

Gilbert, Gregory et al. 2009.Patient Assessment Routine Medical Care-Primary And

Secondary Survey. San Mateo County EMS Agency
Potter & Perry, Ann. 1990. Basic Nursing Theory and Practice 2nd edition. Mosby
Yearbook

SGH-IMSE. n.d.Basic Cardiac Life Support (Bcls)- Institute for Medical Simulation
& Education. Singapore General Hospital
Anonymous. 2010. Resuscitation Guideline 2010. Resuscitation Council (UK)

Anonymous. When to start CPR & How to do it properly.Bensonsheng

Wordpress.com.http://bensoncheng.wordpress.com/2010/03/18/when-to-start-
cpr-and-how-to-do-it/cpr/(accessed June 19th 2012)

Anonymous. 2007. First Aid English Wikibooks. September, 19 th 2007

Anonymous. http://www.cpraccess.com/index.php/page/firstaid_course/33
(Accessed Jun2 18th 2017)

http://www.infobarrel.com/Principle_And_Practice_Of_Emergency_Managemen
t (Accessed Jun2 18th 2017)

http://madzmas.hubpages.com/hub/PRINCIPLES-OF-EMERGENCY-CARE
(Accessed Jun2 18th 2017)

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http://chemm.nlm.nih.gov/appendix8.htm ((Accessed Jun2 18th 2017)

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