Assessment Sheet for Critically Ill Patient PDF
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Uploaded by FestiveOrangeTree
Damanhour University
2021
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Summary
This document is an assessment sheet for critically ill patients, from Damanhour university. It details vital signs, past medical history, and physical examination findings, updated 2021.
Full Transcript
Damanhour university Faculty of nursing Critical and emergency department Assessment Sheet for Critically Ill Patient Student name: Hos...
Damanhour university Faculty of nursing Critical and emergency department Assessment Sheet for Critically Ill Patient Student name: Hospital: Group: Unit: Date of assessment: No of assessment: Part I: Patient Admission Data Patient name: Gender: male female Date of admission Age: Diagnosis: Date of M.V: On admission: Chief complain: Mechanism of injury RTA Blunt Falling Motor Vehicle Accident ABCDE approach: Airway Patent: yes No Presence of: Snoring Gurgling Cyanosis Cervical injury Intervention Breathing Regular Irregular RR: ……. Intervention Circulation Pulse: Presence (regular/ irregular) Absent BL.pr……. Capillary refill: < 3 seconds >3 seconds Intervention Disability LOC (AVPU): ……… Pupils: size Equal Unequal Pupils: reaction Brisky Sluggish Fixed Pinpoint Dilated Intervention Exposure Skin temperature: Hypothermia Normothermia Hyperthermia RBS: …..... Intervention Part II: Patient History Past medical history: Respiratory disorders: Yes NO Specify: Cardiovascular disorders: Yes NO Specify: Renal disorders: Yes NO Specify: GIT disorders: Yes NO Specify: Endocrine disorders: Yes NO Specify: CNS disorders: Yes NO Specify: Past surgical history: Yes NO Specify: Family history: Yes NO Specify: Allergy: Yes NO Specify: 1 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department Part III: Physical examination Vital signs: 1. Pulse (b/min): 2. Blood pressure (mmHg): 3. Respiratory rate(c/min): 4. Temperature (0c): 5. Pain: Conscious patients (numerical pain rating scale): Degree of pain: mild moderate sever Unconscious patients (Behavioral pain scale): Degree of pain: no pain maximum pain For intubated patient For non- intubated patient 6. Oxygen saturation (Spo2): 7. Urine: Amount(ml/hr.): ……………. Urine color assessment (using urine color chart): Degree of hydration: Dehydration very dehydrated Hydrated Overhydration 8. Level of consciousness: Conscious Semiconscious Unconscious Not applicable Using FOUR score: Total score: 2 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department Part III: Physical examination Head & Neck Bone deformity Tenderness Swelling Distended neck veinsCervical spine tenderness Laceration Deviated trachea Invasive device Enlarged lymph nodes Others: EENT (Eye, Ear, Nose ,Throat) Redness Sunken Edematous eye Blurred vision Coreneal ulcer EYE Jaundice Discharge Raccoon Visual aid Absence eye movement Ear Ottorrhea Battle's sig Bleeding Discharge Tinnitus Decrease acuity Using hearing aids Invasive devices NOSE Rhinorrhea Septum deviation Deformity Epistaxis Discharge Throat Dry Inflammation Ulcer Abnormal coating Denture &mouth Abnormal odor Invasive devices Chest&Thorax Airentry : Rtl lung: Absence Diminshed Artificial airway : ETT TT Size: …… Fixation point: …. cuff pressure :………. Method of oxgyenation : MV Facemask Nasal cannula FIO2: ……….. Abnormal respiratory findings Crackles Tachypnea Dyspnea Kussumal breath Wheezing Bradypnea Paradoxical movement Cheynostoke breath Dimished chest sound Shallow breath Asymetric chest rising Gasping Sputum Tendernes Unilateral expension Empysema Cough : Productive nonproductive Spontanous Simulated by suction Invasive devices : Chest Tube: Site : Pleural Medistenuam Connected to suction Oscillation: Presence Absence Amount of drainge : ………………… Circulation & Perfusion Bradycardia Tachycardia Delayed capillary refill ( Upper /lower) Irregular rhythm Specifiy :……… Skin color Pale Flushed Ashed Cyanosis Edema Skin condition Dry Hot Warm Pitting degree: ……….. Nonpitting Generalized Localized Vascular access: CVC PC Arterial line Other Vascular site assessment : Redness Swelling Tenderness patent Size: ……… Neurological state Abnormal neuriological findings Aphasic Numbness Slurred speech Dizziness paralysis Tremors Corneal reflex Presence Abscent Riker Sedation-Agitation Scale (SAS): 1.unaroousal 2.very sediated 3.sedated 4.calm &cooperative 5.Agitated 6.very Agitated 7. Dangerously. GIT Abdomen Soft Firm Flat Round Distended Invsive devices Tenderness Ascites Swelling Rigid Bowel sound Normal Hyperactive Hypoactive Diarrhea Constipation Incontinence Melena Bowel elimination Fecal impaction Hematochezia Nutrition Body mass index : Interpretation Method of feeding : Oral Enteral Parenteral 3 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department Nutrtional problems Polyedepsia Dysphagia Anorexia Nasuea Vomiting Delayed gastric emptying Pelvic& Genitalia Invasive devices Size Site Retetntion Dysuria Urgency Frequency Incontinece Olguria Polyuria Anuria Bleeding Discharge Abnormla vaginal discharge Extremities (Assess mobility, joint function) Motor function Rt. arm Lt Arm Rt leg Lt leg Limited range of motion Stiffness Paresis Paralysis Deformity Sensory Function Loss of sensation Numbness Parathesia Circulatory status Absence of peripheral pulse Delayed capillary refill Others( specify) Invasive devices Skin Condition Dry Wet Normal elasticity Bed sores Yes No Grade:…….. Site :…….. Rest & safety Activity of daily living : Need assist (eat – dress- bath) Independent Dependent Falling Risk Age > 65 Physical impairment Medication (diureict – History of fall Cognitive impairemnt analagesia ) Communicaton Able to commuicate Unable to commuicate Barrier for communiaction Nursing diagnosis based on patient`s problems 4 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 5 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 6 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 7 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 8 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 9 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 11 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 11 Critical care and emergency nursing (update 202-2021) Damanhour university Faculty of nursing Critical and emergency department 12 Critical care and emergency nursing (update 202-2021)
