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Secondary survey: SAMPLE Patient one (Symptoms (Pain tool: PQRST (Provokes…
Secondary survey: SAMPLE Patient one
S
ymptoms
Dry cough
Green mucous
SOB
Chest pain on right side. "Squeezing" feeling.
Low body temp.
Pain tool: PQRST
P
rovokes:
What relieves the pain?
What worsens the pain?
Showering had made the pain worse. Extra pillows while sleeping had made the pain slightly better. Controlled breathing had helped. Salbutamol enhaler had not helped
Q
uality:
What does the pain feel like?
Squeezing feeling in right side of chest
R
adiates
Does the pain stay in the same place?
Where does the pain radiate to?
Pain does not radiate anywhere else in the body. Stays locally in the chest
S
trength
pain severity
Pain score between 9 and 10
T
iming
How long does it last for?
When did it start?
Continuous pain which started a week prior. Only had reached a pain score of 9-10 the night of admission
Full set of vitals
HR: 74 BPM
RR: 22 BPM
SpO2: 100%
BP: 114/67
Temp: 36.6'
LOC: alert
Pain: 0
EWS: 2
Mid 30s, Maori female presented into ward with elevated WOB and chest tightness
Give Comfort
Pysychological comfort
Manage increased WOB with nebuliser
Controlled temp.
Family present
History
Mother had chronic asthma. No known heart attacks nor high blood pressure or strokes in family
A
llergies
NKA
M
edications and last taken
2-3 bottles of Salbutamol had been taken prior admission (within two days)
3L of oxygen given noct. shift
P
ast medical history
3x cases of Pneumonia within the past three years
Controlled asthma
Bronchiolitis as a child
Children were sick the past week with the cold
L
ast fluid and food intake
Both non affected
E
vents of admission
Pt. had chest tightness for a week and was showing signs of flu like symptoms. Children were also sick at the time. Chest tightness had increased the night of admission to a pain score of 9. Quality of pain resembled squeezing of the lungs. Green mucous had been coughed up.
Secondary survey
Assessment completed after primary survey. The purpose is to explore symptoms, history, and signs of the patients condition.