Hospital:- Assessment Sheet for the Critically Ill Patient of... · Assessment Sheet for the Critically Ill Patient Biographical data:- Patient name:…………………… Age:……………………

Philadelphia University Nursing Faculty

Date of assessment:

1

Student’s name:-…………………. Instructors’ Name:-………………

Group number:- ………….(……..) Hospital:-………… Unit:-………..

Assessment Sheet for the Critically Ill Patient

Biographical data:-

Patient name:…………………… Age:…………………… Gender :-……………………….

Address:-……………………….. Nationality:-…………... Religion:-………………………

Education:-…………………….. Occupation:-…………… Income:-……………………….

Marital status:-………………… Family is notified:…….. Availability of family:-………..

Date of admission:…………….. R.N & B.N:…………….

Diagnosis:…………………………………………………….. Diet:-………………………….

Primary Assessment (A,B,C,D,E) ( 1 Grade ) Note&

Nursing diagnosis

Airway:

Absence of chest movement □ Central cyanosis □ Foreign material □

Stridor □ Nasal flaring □ Intercostal retraction □

Cervical Spine Injury:

Neck pain □ Numbness □ Loss of movement □ Loss of sensation □ • Is the airway patent, and if not, is any obstruction partial or complete?

• Is the airway protected?

Breathing:

Absence of exhaled air felt from: Nose □ Mouth □ Stoma □

Unilateral chest expansion □ Paradoxical movement □

Rhythm: Irregular □ Pattern: Bradypnea □ Hypoventilation □ Tachypnea □ Hyperventilation □ Cheyne stokes □ Biot's □ • Does the patient look distressed?

• Are they using their accessory muscles?

• Can they talk in full sentences?

• What is their respiratory rate? (Be concerned if >30 or <8 breaths/minute)

• Are they cyanosed? If pulse oximeter available is SpO2 >90%?

Circulation:

Absence of carotid pulse □ Dysrhythmia □ Peripheral cyanosis □

Skin: Cold □ Hot □ Dry □ Wet □

Bleeding □ Site:............................... Severity Mild □ Moderate □ Severe □ • Does the patient look distressed?

• Are they clammy or cold peripherally?

• Is their capillary refill >2 seconds?

• Can you feel peripheral pulses?

• What is their pulse rate? Is it weak? Is it regular?

• Is there an obvious source of bleeding or other fluid loss?

• Is there reason to suspect cardiac failure?


Date of assessment:

2

Disability

AVPU:- Alert □ Verbal response □ Painful response □ Unresponsive □

Pupils: Unequal □ Rt pupil:- Dilated □ Pinpoint □ Fixed □

Lt pupil:- Dilated □ Pinpoint □ Fixed □ • A – They are spontaneously Alert

• V – They will respond to a Verbal stimulus

• P – They will respond only to Painful stimulus

• U – They are Unresponsive

Exposure or Examination(By this stage you will have assessed and taken appropriate measures

to correct any compromise of airway, breathing, circulation or disability, and the patient may now

benefit from a thorough physical examination.)

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SAMPLE history (Subjective data concurrently done with resuscitation)

Symptoms......................................................................................................................

Allergies.......................................................................................................................

Medication(s)...............................................................................................................

Past history of immunization (toxoid).........................................................................

Last meal......................................................................................................................

Event prior to injury/disease........................................................................................

Secondary Assessment

I- Subjective data: ( 1 Grade) ( Source of data :- Patient □ Family □ Staff □ File □ ) ●Present Medical History:- Reason for hospitalization: (chief complaint):- Present history or History of present illness

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● Mechanism of Injury:-

Motor vehicle crash □ ……………………………….. Blunt trauma □ ………………………………………...

Falling down □ ………………………………... Penetrating trauma □ …………………………………..

● Past Medical / Surgical History:-

Childhood illnesses Hospitalizations

Serious \ Chronic illness Immunizations

Current medications Allergies

Accidents\ Injury Last examination date

Operations Obstetric history

Past signs & symptoms

In all body systems

………………………………………………………………………………………

………………………………………………………………………………………

● Family History:-

Heart disease □ Hypertension □ Stroke □ Diabetes □ Blood disorder □ Sickle cell Anemia □ Cancer □

Arthritis □ Mental illness □ Seizure □ Tuberculosis □ Kidney disease □ Allergies □Obesity □ Others ………...


Date of assessment:

3

● Health Habits & Life Style :-

Nutrition \diet

Activity\Exercises

Fluids \ Stimulants

Elimination

Smoking Over counter & illegal

drugs

Alcohol Relationships

Sleep \ Rest

Coping & Stress

management

Environmental hazards Spiritual resources

● Present Complains:- (COLDSPA)

......................................................................................................................................

...................................................................................................................................... If pain

Precipitating factors:………………………………………………….

Quality: Stabbing □ Burning □ Prickling □ Aching □

Cramping □ Pressing □ Squeezing □ Throbbing □

Region …………………………. Radiation:…………………….

Severity: Mild □ Moderate □ Severe □

Time: Continuous □ Intermittent □

Notes&

Nursing diagnosis

● Perception of present Health: ( patient □ family □ staff □ )

- Bad □ Deteriorated □ Hopeless □ Good □ Improved □ Hopeful □

II- Objective data ( 4 Grades) ( Inspection , palpation , percussion & auscultation ) ● General appearance:-

- Weight: Emaciated □ Obese □

- Position:-Fowler □ Semi-fowler □ Lying down □ Leaning forward □

Trendelenburg □ Tripod □ Fetal □ others:-…………………..

- Grooming & hygiene:- Poor hygiene □Total inattention to one side of body □

- Skin: Pale □ Cyanotic □ Flushed □ Jaundice □ Ached □ Dry □ Diaphoresis □

Smooth & Soft □ Rough &,Flaky □ Poor skin turgor □ Edema □ Abnormal finding Site Abnormal finding Site

Swelling Incision

Edema Abrasion

Redness Lacerations.

Hotness Avulsion

Tenderness Impaled object

Contusion Surgical wound

Ecchymosis Previous scar

Hematoma. Decubitus ulcer:-………………………….

……………………………………………. Others:- …………………………………...

Notes&

Nursing diagnosis


Date of assessment:

4

● Vital signs:-

Temperature: -Axillary ……....ºC Hyperthermia □ Hypothermia □

Respiration:-………C/m. Spontaneous □ Assisted □ Controlled □ SPO2:- ……%

Bradypneia □ Hypoventilation □ Tachypnea □ Hyperventilation □

Frequent sigh □ Cheyne- stockes □ Biot's respiration □ Chronic obstructive □

Pulse: -Apical: -…….B/ m.Radial:-…….B/m. Bradycardia □ Tachycardia □

Dysrhthmia□ …………………………………………………………………..

Not palpable □Weak thready □ Full, bounding □ Water-hammer □

Pulsus bigeminus □ Pulsus alternans □ Pulsus paradoxus □ Pulsus bisferiens □

Blood pressure:- Non invasive □ Invasive □ Systolic blood pressure:-…...mmHg

Diastolic blood pressure:-……...mmHg . Pulse pressure :- ……….mmHg

Mean arterial pressure (MAP):-…….. mmHg. C.V.P:-………CmH2O\ mmHg.

Hypertension □ Hypotension □ Orthostatic hypotension □ ………………………...

Head to Toe Assessment (4 Grades) ● Head:-

Size & shape:- Deformities □ Lumps □ Depressions□ Abnormal protrusions □

Temporal area :- Temporal artery:- Tortuous □ Hard □Tender □

Temporomandibular joint:- Swelling □ Tenderness □

Grinding of jaws □ Crepitation □ Limited ROM □

Facial structures:- Hostility □ Embarrassment □ Tense strained tired □

Grimacing □ Flat masklike □ Excessive smiling □ Edema □

Marked asymmetry □ Tics □ Excessive blinking □

Others:- ......................................................................................................................


Date of assessment:

5

● Eye:-

Visual acuity & field Hesitancy □ Leaning forward □ Presbyopia □

Loss of vision □ Decreased acuity of vision□ Peripheral field loss □ ………

Extraocular muscle function:- □ Squinting □ Nystigmus □

Eyebrows:- Unequal movement □ Absent movement □ Scaling □

Lid:- □ Incomplete closure □ Ptosis □ Periorbital edema □

Raccoon eye □ Sunken

Eyeballs:- Exophthalmos □ Enophthalmos □

Conjunctivae (lower lids ) Redness □ Cyanosis □ Pallor near outer canthus □

Sclera:- Scleral icterus □Tenderness □ Foreign body □ Discharge □ Lesions □

Lacrimal apparatus:- Swelling of lacrimal gland □ Red swollen tender puncta □

Regurgitation of fluid out of puncta □

Cornea & lens:- Abrasion □

Iris & pupils :- Irregular □ Oval □ Unequal size □ Dilated □ Fixed □

Constricted □ Unequal response to light □

Others:-..............................................................................................................

● Nose:-

External nose Absence of sniff □ Deformity □ Nasal flaring □

Nasal cavity Mucosa:- Swollen □ Bright red □ Boggy pale □ Gray □

Discharge:- Watery □ Copious □ Thick □ Purulent □

Green □ yellow □ Rhinorrhea □ Epistaxis □

Septum:- Deviated □ Perforated □ Polyp □ Foreign body □

Sinus area:- Tender □ Filled with fluids □ Unilateral □ Bilateral □

Others:-............................ Invasive devices:-………………………………………

● Mouth:-

Lips:- Pallor □ Cyanosis□ Cherry red □ Cheilitis □ Herpes simplex □

Teeth:- Brown □ Yellow □ Grinding down of tooth surface □ Plaque□ Caries□

Gums:- Hyperatrophy □ Gingivitis □ Dark line on gingival margin □

Tongue:- Beefy red □ Swollen □ Smooth glossy areas □ Enlarged □ Small □

Dry □ Deep vertical fissures □ Abnormal coating □ Ulcer□

Deviated □ Tremor □ Decreased saliva □ Excess drooling saliva □

Buccal mucosa:- Patch □ Ulcer □ Lesion □

Palate:- Yellow □ Green brown □ Bifid uvula □ Deviated uvula□

Tonsils:- Bright red □ Swollen □ Exudates □ Large white spots □ Enlarged □

Breath odor:- Sweet fruity □ Acetone □ Ammonia □ Musty □ Foul fetid □

Alcohol □ Mouse like □

Speech:-Unable □ Slurred □ Slow monotonous □ Rapid-fire, pressure &loud □

Global aphasia □ Expressive aphasia □ Receptive aphasia □

Others:- ......................................... Invasive devices:- ……………………………


Date of assessment:

6

● Ear:-

Shape & size:- Microtia □ Macrotia □ Edema □

Skin condition:- Redness □ Excessively warm□ Crusts□ Scaling□

Enlarged tender lymph nodes□ Battle’s sign □

Tenderness:- Pain with movement □ Pain at mastoid process □

External auditory meatus:- Atresia □ Sticky yellow discharge □

Impacted cerumen □ Ottorrhea □ Blood □

Hearing acuity:- Unable to hear whispered words □ Decreased acuity □

Others:-.............................................................................................................

● Neck:-

Symmetry:- Head tilt to one side □ Rigid head & neck□

Cervical spine:- Range of motion:- Pain with movement □ Tenderness □

Swelling □ Ratchy movement □ Limited movement □ Can't hold flexion □

Lymph nodes Parotid swelling □ Parotid Enlargement □ Lymphadenopathy □

Bilateral enlargement□ Unilateral enlargement □ Warm □ Tender □ Firm □

Clumped □ Hard □ Fixed □ Rubbery □ Discrete□

Trachea:- Tracheal shift □ ………………….. Tracheal tug □

Thyroid:- Unilateral enlargement □ Nodules □ Lump□ Diffuse enlargement □

Tender □ Bruit □

Muscles:- Hypertrophy □ Use of accessory muscle during inspiration □

Asymmetry of muscles □ Hard muscles □

Vessels:- Carotid artery:- Hypersensitivity □ Diminished pulse □

Increased pulse □ Bruit □

Jugular veins:- Unilateral distension □ Full distended above 45 degree □

Elevated pressure□ Sustained elevated pressure □

Others:- ..................................... Invasive devices:- ………………………………

● Chest:-

Shape & configuration:- Barrel chest □ Scoliosis □ Kyphosis □ others ……….

Chest expansion:- Unequal expansion □ Unilateral Paradoxical movement □

Wide costal angle □ Lag in expansion □

Intercostals muscles:- Retraction □ Bulging □

Fremitus:- Decreased tactile fremitus □ Increased tactile fremitus

□Crepitus(rales)

Lung field:- Hyperresonance □ Dullness □

Absence of diaphragmatic excursion □Abnormally high level of dullness □

Breath sounds:- Decreased □ ………. Absent □ ………. Increased □ …………

Adventitious sounds:- Crackles (rales) □ ……….Wheeze (rhonchi) □ ………...

Voice sounds:- Increased □ ……………………………………………………...

Cough:- Dry □ Hacking □ Barking □ Congested □ Wet □


Date of assessment:

7

Sputum:- Amount:- Small □ Moderate □ Large □ Odor:- Offensive odor □

Color:- White □ Yellow □ Green □ Pink □ Rust □ Red □ Black □

Consistency:-Thick □ Watery □ Frothy □ Content :- Hemoptysis □Mucous

Amount:- Small □ Moderate □ Large □ Odor:- Offensive odor □

Others:- ................................... Invasive devices:- …………………………

● Precordium:-

Pulsations:- Heave \ Lift □

Apical impulse:- Displaced down and to the left □ Increased force & duration □

Not palpable □ Thrill □ Accentuated S1 □ Accentuated S2 □

Heart sounds:- Premature beat □ Irregularly irregular □ Pulse deficit □ Pathological S3 □ Pathological S4 □ Systolic murmur □ Diastolic murmur □

● Abdomen:-

Contour:- Scaphoid □ Protuberant □ Distension □

Symmetry:- Bulges □ Masses □ Hernia □ Localized bulging □

Umbilicus:- Everted □ Deeply sunken □ Enlarged □ Inverted

Skin:- Redness □ Jaundice □ Glistening □ Taut □ Striae □ Purple –blue □

Unusual color\Change in shape of mole □ Spider nevi □ Poor turgor □

Prominent dilated veins □ Visible veins □ Rashes □……Lesions □ …….

Pulsation&Movement:-Marked pulsation of aorta □Marked visible peristalsis □

Demeanor:- Restlessness □ Absolute stillness □ Knees fixed up □

Bowel sounds:- Rate………………..Hyperactive □ Hypoactive □ Absent □

Vascular sounds:- Systolic bruit □ Peritoneal friction rub □

General tympany:-Distended bladder □ Fluid □ Mass □ Gaseous distension □

Enlarged liver□ Enlarged spleen □ Positive fluid wave□ Shifting dullness□

Rebound tenderness □

Muscle:-Guarding □ Rigidity □ large masses □ Tenderness □ Hypertrophy □

Costovertebral angle:- Enlarged kidney □ Mass □ Tenderness □

● Nutritional problems

Vomiting□ ……………………………………………………….Hematemesis □

Delayed gastric emptying □ Amount aspirated………………………………….

●Elimination problems:

Bowel :- Incontinence □ Diarrhea □ Melena □ Constipation □ Fecal impaction □

Urinary:- Retention □ Incontinence □ Polyuria □ Oliguria □ Anuria □

Others.......................................... Invasive devices……………………………..

●Pelvis and genitalia:

Bone deformity □ Bleeding urinary meatus □ Vaginal discharges □


Date of assessment:

8

● Extremities:

Abnormal findings Rt arm Lt arm Rt leg Lt leg

Bone & Joint Deformity Swelling Local heat Local tenderness Crepitus Limited ROM Increased ROM Joint Stiffness

Muscle Atrophy Hyperatrophy Contructure

Circulation Cold Pallor Erethema Cyanosis edema Varicosities Positive Homan's sign Thin shiny skin Absence of pulse

Weak pulse Bruit over femoral artery D .capillary refill Clubbing of nails Enlarged lymph n

Movement Paresis Plegia Flaccidity Spasticity

Sensation Hypalgesia Analgesia Hyperalgesia hypoesthesia Anesthesia Hyperesthesia Parasthesia Numbness

Reflexes Hyperreflexia


Date of assessment:

9

Hyporeflexia Absent reflexes

Others:- ………………………………. Invasive devices:-………………………...

● Functional status:

- Energy level: Exhausted without activity □ Tires easily □

- Activity of daily living:

Dependent □ Need assistance with: Eating □ Dressing □ Bathing □ Toileting □

- Mobility status:

Immobile □ Mobile with assistance of other person □

Mobile with device: Crutch □ Wheel chair □ Walker □

Physical handicap □ ........................................................

● Nutritional status :-

Nutritional problems :- Anorexia □ Nausea □ Altered taste □ Altered smell □

Chewing difficulty □ Dysphagia □ Polydepsia □ Polyphagia □

Anthropometric measurements:- Weight:- ……….. Height:- …………… Current Weight

Percent ideal body weight :--------------------- X 100 = --------- X 100 =

Ideal Weight

Mild malnutrition □ Moderate malnutrition □ Severe malnutrition □ obesity □

Body mass index = Weight ( in kilograms)

----------------------------- = --------------------- =

Height (in meters)2

Underweight □ Overweight □ Obesity □ Extreme obesity □

Caloric intake:- ( for enteral & parenteral nutrition)

……………………………………………………………………………………..

……………………………………………………………………………………..

● Psychological status:

Flat □ Inappropriate □ Fearful □ Apprehensive □ Anxious □ Irritable □

Sad □ Aggressive □ Angry □ Withdrawn □ Depressed □ Despair □

● Mental status:-

Behavior: - Level of consciousness:- Alert □ Lethargic □ Obtunded □

Stupor \ Semi-coma □ Coma □

Cognitive functions:- Disoriented to:- Time □ Place □ Persons □

Decreased attention □ Recent amnesia □ Remote amnesia □

Thought processes & perceptions:- Illogical unrealistic thought □ …………….

Delusion □ Illusion □ Hallucination □ …………………….

●Teaching needs: ( Patient □ Family □ Both □ )


Date of assessment:

10

……………………………………………………………………………………...

……………………………………………………………………………………...

Abnormal results of diagnostic procedures and laboratory investigations (1 Grade)Last Diagnostic Procedures

Name of Procedure Date Result Interpretation

Last Laboratory Investigations

Name of Lab. Test Date Result Normal value Interpretation

Current medications & Infusions (1 Grade) Current Medications

Medication’s Name Action/

Classification

Dose Route Frequency Nursing Considerations


Date of assessment:

11

Current IV Infusions

Infusion ‘s Name Concentration Type Amount Frequency Nursing Considerations

Sedation Scale (0.5 Grade)

Ramsay Sedation Scale Points

-Anxious and / or agitated 1

-cooperative, oriented and tranquil 2

-Responsive to commands 3

-Asleep , responds briskly to light glabellar or loud auditory stimuli 4

-Sluggish response to light glabellar tap or loud auditory stimuli 5

-Unresponsive to stimuli 6

Related nursing diagnosis:-…………………………………………………………………………………

Trauma Scale (1.5 Grade)

Items Value Points Score

Systolic BP (mmHg)

> 90

70-89

50-69

0-49

no pulse

4

3

2

1

0

A..........

Respiratory Rate/ min 10-24

25-35

> 36

1-9

none

4

3

2

1

0

B...........

Glasgow Coma Scale Total GCS points Points Score

1- Eye opening

- Spontaneous

- To voice

- To pain

- None / (C) for closed eye

4

3

2

1

13-15

9-12

6-8

4-5

< 4

4

3

2

1

0

C...........

2- Verbal response

- Oriented

- Confused

- Inappropriate words

- Incomprehensive ward

- None / (T )for ETT \ TT

5

4

3

2

1


Date of assessment:

12

3- Motor response (response

to command or painful stimulus

- Obeys commands

- Localizes pain

- Withdraw (pain)

- Flexion (pain)

- Extension (pain)

- None / (Q) for quadriplegia

6

5

4

3

2

1

Total GCS points = 1+2+3= ………………………….

Trauma score = (A+B+C) =……………

Related Nursing diagnosis:-…………………………………………………………………………………

Nursing care plane (According to Priorities) (10 Grades)

Assessment Nursing

diagnosis

planning Intervention Evaluation


Date of assessment:

13

Documents

Hospital:- Assessment Sheet for the Critically Ill Patient of... · Assessment Sheet for the Critically Ill Patient Biographical data:- Patient name:…………………… Age:……………………