Document Assessment Record Instructor

Score

Critical care Nursing Assessment Form

Patient’s name :…………………………………………………... Student’s name :…………………………………………………..
Age: ………………………. Sex :……………………………. Code :………………………………………………………………
Date of hospital admission :……………………………………… Group No: ………………………...………..……………………..
Date of ICU admission :…………………………………………. Date of assessment: ……………………..………………………..
Days in ICU :…………………………………………………….. Unit: …………………….…….…………………………………..
Diagnosis :…………………………………………………………………………………………………………………………………...
Special considerations :……………………………………………………………………………………………………………………..
Primary Assessment/Interventions (done within first 24 hours from admission and any change in the patient’s condition)
Airway: Snoring Gurgling  Hoarseness  Central cyanosis  Stridor
Cervical spine injury:
 Neck pain  Numbness  Loss of movement  Loss of sensation
Interventions………………………………...……………………………………………………………
Breathing:  Apnea  Bradypnea  Tachypnea  Dyspnea
 Shallow  Deep  Wheezes Nasal flaring
R.R:…………  Use of accessory muscles  Kussmaul’s respiration
 Gasping respiration  Cheyne-stoke respiration
 Paradoxical chest movement  Unilateral expansion
 Intercostal retraction  SpO2 Saturation……...…………………%
Interventions…………………..…………………….……………………………………………………
Circulation Pulse : ………………………….  Absent  Bradycardia  Tachycardia
 Irregular  Weak  Thready
B.P:………… MAP:……………………………………………….. Pulse pressure :……………………………………..
Bleeding check if found……….…….  Mild  Moderate  Severe
Skin : Color Pink Cyanosis Pallor Jaundice
Flushed Erythema Ashed
Temperature Cold Warm Hot
Capillary Refill…………………………………………………………………………………………………..seconds
Interventions…………………………………………………………………………………………………
Disability Level of Consciousness (AVPU)
 Alert  Verbal response  Painful response  Unresponsive
Pupil Size RT Eye:………. LT Eye:………..  Equal  Not equal
Reaction RT Eye Brisky Sluggish Fixed
LT Eye Brisky Sluggish Fixed
Pupil reactivity score :  2: Both not react 1:One not react 0: Both react.
Blood glucose level………..………………………………………………………….…………mg/dl
Exposure Describe any abnormalities in the patient’s body:……………………………………………………………………………….
Secondary Assessment
I. History
a. (Chief complaint)…………………………………………..………………………………………………………………………………
b. Mechanism of injury(in trauma only ):  Blunt trauma  Fall  Penetrating trauma  Motor vehicle crash
c. SAMPLE history Signs and Symptoms ……………………………………….………………………………………………
Allergies (Medications, food, etc.) ………………………………………….…………………………......
Medications (Prescribed or Over-the-counter)…………………………………..………………................
Past Pertinent History………………………………………….……….…………………………………..
Last Oral Intake (Fluid or Solid)………………………………………….………..………………………
Events leading to history of present illness …………..………………………….………………...............
d. Family History :……………………………………………………………………………………………………………….

(CEN-001) Critical care and Emergency Nursing Department (2022) 1

II. General Survey
A. Skin Color Pink Cyanosis Pallor Jaundice
Flushed Erythema Ashed
Temperature Cold Warm Hot
B. Odor  Alcohol  Acetone  Urine  Feces
C. Baseline Vital Signs Temp …..…..OC  RR …………..C/Min  HR …………..………..B/Min

 B.P ………......mmHg  SPO2…..……% R.B.S …………..……..mg/dl

D. Level of consciousness (Glasgow Coma Scale)

Eye opening Verbal response Motor response
Spontaneous 4 Oriented 5 Obeys commands 6
To voice 3 Confused 4 Localizes pain 5
To pain 2 Inappropriate words 3 Normal flexion 4
None 1 Sounds 2 Abnormal flexion 3
Non-Testable (one reason) 1 None 1 Extension 2
……………………………. Non-Testable (one reason) 1 None 1
………………………………….. Non-Testable (one reason) 1
…………………………………………..
Total GC. Score: …………………………………………………………………………………………….
Full Outline of Unresponsiveness Score (FOUR score )
Eyelids open, opened, tracking, or blinking to command 4
Eyelids open but not tracking. 3
Eye response Eyelids closed but open to loud voice 2
Eyelids closed but open with pain 1
Eyelids remain closed with pain 0
Thumbs-up, fist, or peace sign 4
Localizing to pain 3
Motor response Flexion response to pain 2
Extension response to pain 1
No response to pain or generalized myoclonus status 0
Papillary and corneal reflexes present 4
One pupil wide and fixed 3
Brainstem reflexes Papillary or corneal reflexes absent 2
Papillary and corneal reflexes absent 1
Absent Papillary, corneal, ands coughing reflexes 0
Not intubated , regular breathing pattern 4
Not intubated , Cheyne-stokes breathing pattern 3
Respiration Not intubated ,irregular breathing 2
Breathes above the preset ventilator rate 1
Breathes at the preset ventilator rate or apnea 0
Total FOUR Score
III. Head to toe assessment
Head & face
 Bone deformity  Bruises  Laceration  Swelling
 Tenderness Others…………………………………………………………………………………......

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(CEN-001) Critical care and Emergency Nursing Department (2023)
Eye :

 Ptosis  Excessive blinking  Extraocular movements  Discharge

 Swelling  Ecchymosis  Hemorrhage  Injuries
 Raccoon eye  foreign body  Loss of vision  Blurred vision
Others………………………………………………………………………………….....................................................................................
Ear
 Deformity  Discharge  Hemorrhage  Foreign body
 Otorrhea  Injuries  Battle’s sign  Tinnitus
Decreased acuity Others………………………………………………………
Nose
Injuries Deformity Epistaxis Rhinorrhea Nasal septum deviation
Discharge Invasive devices & size ……………………………………………………………..……………………
Others…………………………………………………………………………………....................................................................................
Mouth
Dry Ulcer Inflammation Abnormal coating
Injuries Hemorrhage Foreign body Missing or broken teeth
Unable to speak Slurred speech Aphasia
Invasive devices & size ……………………………………………………………………. Other…………………………………..
Neck
Deformity Swelling Deviated trachea Distended neck veins
tenderness Enlarged lymph nodes
Invasive devices & size ……………………………………………………………… Other…………………………………..
Chest& thorax
Deformity Tenderness Subcutaneous Emphysema
Asymmetry  Unilateral expansion Paradoxical movement Nasal flaring
Tachypnea Bradypnea Use of accessory muscles Gasping respiration
Deep Shallow Kussmaul’s respiration Cheyne-stoke respiration
Dyspnea Sputum(Color ……..……………..…, Consistency……………….)
Air entry Rt lung Normal Diminished Absent
Lt lung  Normal  Diminished  Absent
Breathing sounds N: Normal
C: Crackles
W: Wheezy
Invasive devices &size ……………………………………………………………………………….
Chest tubes : Anatomical site :……………………………………………………………
Present Oscillation: Present Absent
Absent Air leak : Present Absent
Zero Level ………..CC Drainage Bloody Serous Serosanguinous
Surgical Emphysema: Present Absent
Other ………………………………………………………...........................................................................................................................
Abdomen & Flank
Tenderness Swelling Rigid Soft
Flat Distended Exposed internal organ
Dilated veins Polydipsia Polyphagia
Vomiting on NGD Delayed gastric emptying Abdominal girth.........cm
Bowel sounds:………C/Min Absent  Hypoactive  Normal Hyperactive
Invasive devices &size ……………………………...... +++++:Incision
Other…………………………………………………… X:Drain
////:Bruising
>:Stab site
o :Ostomy

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(CEN-001) Critical care and Emergency Nursing Department (2023)
Pelvis& genitalia
Anuria Oliguria Polyuria Urgency
Frequency Dysuria Retention  Urine Incontinence
Hematuria Urinary Discharge Fecal impaction  Stool Incontinence
Constipation Diarrhea Melena Hematochezia
Vaginal Bleeding Abnormal vaginal discharge
Invasive devices& size ……………………………... Other ………………………………………………………...............................
Extremities
Assessment parameter Rt. arm Lt. arm Rt. leg Lt leg Remarks
Color
Temperature
Motor Function Limited ROM
(for conscious only) Paresis
Paralysis
Sensory Function Loss of sensation
(for conscious only ) Paresthesia
Peripheral pulse
Capillary refill timing
Edema scale
Others (Cast, Fixators, Amputation)
Invasive devices
Posterior surface
Tenderness Swelling Bed sores Site :…………………….. Grade :…………………
Others…………………………………………………………………………………........................................
Braden scale for Assessing risk for pressure ulcers:
1 2 3 4
Sensory perception Completely limited Very limited Slightly limited No impairment
Moisture skin Constantly moist Very moist Occasionally moist Rarely moist
Activity Bed ridden Chairfast Walks occasionally Walks frequently
Mobility Completely immobile Very limited Slightly limited No limitations
Nutrition Very poor Probably inadequate Adequate Excellent
Friction / shear Problem Potential problem No apparent problem
Total score: *Risk for pressure ulcers:
*risk: ≤12 : High risk , 13-15 : Moderate risk , 16-17: Mild risk , ≥18:Average
Psychological status
Fear Anxiety Aggression Withdrawal
Others………………………………………………………………………………….................................................
IV. laboratory values
Test Hb HCT RBCS WBCS PLTS Na K Mg BUN Cr
Result
Test Bili. (Tot.) SGPT SGOT CK-MB Troponin. I PT PTT INR CRP
Result
Test
Result
Modified APACHE II scoring:
A-Acute physiology score 4 3 2 1 0 1 2 3 4
Mean BP (mmHg) ≤49 50~69 70~109 110~129 130~159 ≥160
Serum Sodium (mmol/L) ≤110 111~119 120~129 130~149 150~154 155~159 160~179 ≥180
Serum Potassium (mmol/L) <2.5 2.5~2.9 3.0~3.4 3.5~5.4 5.5~5.9 6.5~6.9 ≥7.0
Serum Creatinine (Mg/dL) <0.6 0.6~1.4 1.5~1.9 70~109 ≥3.5
Total Glasgow coma scale 15 - (actual GCS)
Total Acute physiology score
B- Age points 0 2 4 5 6
≤44 45~54 55~64 65~74 ≥75
TOTAL APACHE.II= A+B=

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(CEN-001) Critical care and Emergency Nursing Department (2023)
V. Diagnostic studies (most recent):
Study Date Result
ECG ……………. Rate :…………………………rhythm:……………………………………………………………………………………
X-ray ……………. ………………………………………………………………………………………………………………………………………………
CT …………….
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MRI …………….
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U/S …………………………………………………………………………………………………………………………………………….....
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Doppler …………….
…………………………………………………………………………………………………………………………………………….....
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Echo …………….
EF(LVEF):…………% ,RESULT :……………………………………………………………………………………………….........
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EEG …………….
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Sepsis lab work :
Culture Date Resulted organism Current Anti-microbial therapy
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VI. Medications and infusions( documented by the physician ):
Name Action Dose Route Frequency Method of preparation (for infusions)
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Student’s signature :…………………………………………………………………………………………………………………………..

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(CEN-001) Critical care and Emergency Nursing Department (2023)