Assessment sheet
Special unit: Critical Care Dep.
- Sheet no:
Student name: Hossam El-Deen Hamda
 Pt name:
 Age:
Sex:
 Admission date:
 Marital status: M ( )
S(
 Religion:
 Nationality:
 Height:
Present History:
 Diagnosis:
 Chief complaints on admission:
 Associated signs and symptoms:
 Onset /Duration /Frequency:
 Predisposing factors:
Past history:
 Medical:
 Surgical:
Family History:
)
W(
)
D( )
systems
Respiratory
Items
Abnormal pattern:-Irregular
-labored
-Dyspnic
-Tachypenic
Cough:-productive
-Non productive
secretions:
-clear
-yellow
-Green
-Blood-tinged
-Thin
-Thick
Need for suction:-es
-No
Need for oxygen therapy:-Room air
-Nasal canula
-Mask
-Non rebreather
-Endotracheal tube
-Tracheostomy
Chest tube
Cardiovascular
Peripheral pulse
scale:Zero: absent pulse
+1: thread pulse
+2 :weak pulse
+3 normal pulse
Comparative peripheral
pulse
Right radial pulse
Left radial pulse
Right pedal pulse
Left radial pulse
+4 bounding pulse
Capillary refill3 second
Yes
No
Remark
Nursing Diagnosis
systems
Neurological
Gastrointestinal
integumentry(
skin )
Items
Edema :-Generalized
-Localized
Glasgow coma scale:
Eye opening:
Spontaneously :(4)
To speech (3)
To pain (2)
No response(1)
Best verbal :
Oriented ( 5)
Confused (4)
Inappropriate word (3)
Incomprehensive sound (2)
No response (1)
Best motor response:
Obey commands (6)
Localized pain (5)
Flexion to pain (4)
Decorticate (3)
Decerbrate (2)
No response (1)
Total score:
Pupils Rt/Lt
Fixed
Pinpoint
Sluggish
Unequal
Convulsion
Eating abnormalities
Difficulties chewing
Difficulties swallowing
Tenderness of abdomen
Nausea
Vomiting
Bowel sound
Normal
Hypoactive
Hyperactive
skin condition
-Cold &clammy
-Hot and dry
Remark
Nursing Diagnosis
systems
Pressure ulcer
Musculoskeletal
urinary
Psychological
Sleep
Items
Color
-Pale
-Flushed
-Jaundiced
-Cyanotic
turgor:
-Fair
-Sluggish
-Poor
skin rash
site
Abnormal findings of
limbs:-extremity weakness (paresis
)
Unsteady gait
Contracture of joint
Paresthesia
Paralysis
Amputation
Assistive device:
-wheel chair/walker
-cane/crutches
-prothesis
Traction
-skin traction
-skletal traction
Cast
abnormal findings:
-incontinent
-Hematuria
-Dysuria
-Urgency
-Urinary catheter
Psychological Abnormal
findings:
-Anxious
-Flat affect
-Combative
-Suicide precaution
-Hours of sleeping at night
-Hours of sleeping at naps
-Sleeping aid
Remark
Nursing Diagnosis
systems
Activities of daily
living:
-Independent(3)
-Need
assistance(2)
-Dependant
Items
-Difficulty failing sleep
*feeding
Remark
Nursing Diagnosis
*Bathing
*Dressing
*Toileting
*Transferring
*Walking
Assessment of pain:
Date
Location
Intensity
frequency
Duration
Diagnostic measures:Lab investigation:
Lab investigation
Results
Normal ranges
Comment
Radiological examination:
Type of examination
Results
Medical Management:
Name
route
Dose
Frequency
NURSING CARE PLAN
Patient's name:
Nursing diagnosis Expectedoutcome
Medical diagnosis:Group no:
Implementation
Student name:
Rationale
Evaluation
NURSING CARE PLAN
Patient's name:
Nursing diagnosis Expectedoutcome
Medical diagnosis:Group no:
Implementation
Student name:
Rationale
Evaluation
NURSING CARE PLAN
Patient's name:
Nursing diagnosis Expectedoutcome
Medical diagnosis:Group no:
Implementation
Student name:
Rationale
Evaluation