Philadelphia University
Student’s name:-………………….
Group number:- ………….(……..)
Nursing Faculty
Instructors’ Name:-………………
Hospital:-………… Unit:-………..
Assessment Sheet for the Critically Ill Patient
Biographical data:Patient name:…………………… Age:……………………
Address:-………………………..
Nationality:-…………...
Education:-……………………..
Occupation:-……………
Marital status:-…………………
Family is notified:……..
Date of admission:……………..
R.N & B.N:…………….
Diagnosis:……………………………………………………..
Gender :-……………………….
Religion:-………………………
Income:-……………………….
Availability of family:-………..
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?
1
Date of assessment:
Philadelphia University
Nursing Faculty
Disability
Alert □ Verbal response □ Painful response □ Unresponsive □
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
AVPU:Pupils:
to correct any compromise of airway, breathing, circulation or disability, and the patient may now
benefit from a thorough physical examination.)
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
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
.....................................................................................................................................................................................
.....................................................................................................................................................................................
● 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 ………...
2
Date of assessment:
Philadelphia University
Nursing Faculty
● Health Habits & Life Style :Nutrition \diet
Activity\Exercises
Fluids \ Stimulants
Elimination
Smoking
Over counter & illegal
drugs
Relationships
Coping & Stress
management
Spiritual resources
Alcohol
Sleep \ Rest
Environmental hazards
● Present Complains:- (COLDSPA)
......................................................................................................................................
......................................................................................................................................
Notes&
Nursing diagnosis
If pain
Precipitating factors:………………………………………………….
Quality: Stabbing □ Burning □ Prickling □ Aching
□
Cramping □ Pressing □ Squeezing □ Throbbing □
Region …………………………. Radiation:…………………….
Severity: Mild
□ Moderate □ Severe
□
Time: Continuous □ Intermittent □
● 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
Swelling
Edema
Redness
Hotness
Tenderness
Contusion
Ecchymosis
Hematoma.
Others:- …………………………………...
Notes&
Nursing diagnosis
Abnormal finding
Site
Incision
Abrasion
Lacerations.
Avulsion
Impaled object
Surgical wound
Previous scar
Decubitus ulcer:-………………………….
…………………………………………….
3
Date of assessment:
Philadelphia University
Nursing Faculty
● 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:- ......................................................................................................................
4
Date of assessment:
Philadelphia University
Nursing Faculty
● 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:- ……………………………
5
Date of assessment:
Philadelphia University
Nursing Faculty
● 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 □
6
Date of assessment:
Philadelphia University
Nursing Faculty
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 □
7
Date of assessment:
Philadelphia University
Nursing Faculty
● Extremities:
Abnormal findings
Bone & Joint
Rt arm
Lt arm
Rt leg
Lt leg
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
8
Date of assessment:
Philadelphia University
Nursing Faculty
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 □ )
9
Date of assessment:
Philadelphia University
Nursing Faculty
……………………………………………………………………………………...
……………………………………………………………………………………...
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
10
Date of assessment:
Philadelphia University
Nursing Faculty
Current IV Infusions
Infusion ‘s Name
Concentration
Type
Amount
Frequency
Nursing Considerations
Sedation Scale (0.5 Grade)
Ramsay Sedation Scale
-Anxious and / or agitated
-cooperative, oriented and tranquil
-Responsive to commands
-Asleep , responds briskly to light glabellar or loud auditory stimuli
-Sluggish response to light glabellar tap or loud auditory stimuli
-Unresponsive to stimuli
Points
1
2
3
4
5
6
Related nursing diagnosis:-…………………………………………………………………………………
Trauma Scale (1.5 Grade)
Items
Systolic BP (mmHg)
Respiratory Rate/ min
Glasgow Coma Scale
Value
> 90
70-89
50-69
0-49
no pulse
10-24
25-35
> 36
1-9
none
Total GCS points
Points
4
3
2
1
0
4
3
2
1
0
Points
13-15
9-12
6-8
4-5
<4
4
3
2
1
0
Score
A..........
B...........
Score
1- Eye opening
- Spontaneous
- To voice
- To pain
- None / (C) for closed eye
2- Verbal response
- Oriented
- Confused
- Inappropriate words
- Incomprehensive ward
- None / (T )for ETT \ TT
4
3
2
1
C...........
5
4
3
2
1
11
Date of assessment:
Philadelphia University
Nursing Faculty
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
12
Date of assessment:
Philadelphia University
Nursing Faculty
13
Date of assessment: