ASSEMENT HEET FOR THE CRITICALLY ILL OR INJURRED CLIENT
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 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? | |
|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.) | |
|……………………………………………………………………………………………………………… | |
|……………………………………………………………………………………………………………… | |
|……………………………………………………………………………………………………………… | |
|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 □ ………………………………………... |
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|Falling down □ ………………………………... Penetrating trauma □ ………………………………….. |
|● Past Medical / Surgical History:- |
|Childhood illnesses |
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|Hospitalizations |
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|Serious \ Chronic illness |
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|Immunizations |
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|Current medications |
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|Allergies |
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|Accidents\ Injury |
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|Last examination date |
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|Operations |
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|Obstetric history |
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|Past signs & symptoms |
|In all body systems |
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|……………………………………………………………………………………… |
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|● Family History:- |
|Heart disease □ Hypertension □ Stroke □ Diabetes □ Blood disorder □ Sickle cell Anemia □ Cancer □ Arthritis □ Mental illness □ Seizure □ Tuberculosis □ Kidney |
|disease □ Allergies □Obesity □ Others ………... |
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|● Health Habits & Life Style :- |
|Nutrition \diet |
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|Activity\Exercises |
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|Fluids \ Stimulants |
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|Elimination |
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|Smoking |
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|Over counter & illegal drugs |
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|Alcohol |
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|Relationships |
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|Sleep \ Rest |
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|Coping & Stress management |
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|Environmental hazards |
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|Spiritual resources |
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|● 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 ) |Notes& |
|● General appearance:- |Nursing diagnosis |
|- 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 | |
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|Swelling | |
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|Incision | |
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|Edema | |
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|Abrasion | |
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|Redness | |
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|Lacerations. | |
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|Hotness | |
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|Avulsion | |
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|Tenderness | |
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|Impaled object | |
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|Contusion | |
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|Surgical wound | |
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|Ecchymosis | |
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|Previous scar | |
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|Hematoma. | |
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|Decubitus ulcer:-…………………………. | |
|……………………………………………. | |
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|Others:- …………………………………... | |
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|● 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:- | |
|...................................................................................................................... | |
| | |
|● 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:- …………………………… | |
|● 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:- | |
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|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 □ | |
|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 □ | |
|● Extremities: | |
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|Abnormal findings | |
|Rt arm | |
|Lt arm | |
|Rt leg | |
|Lt leg | |
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|Bone & Joint | |
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|Deformity | |
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|Swelling | |
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|Local heat | |
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|Local tenderness | |
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|Crepitus | |
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|Limited ROM | |
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|Increased ROM | |
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|Joint Stiffness | |
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|Muscle | |
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|Atrophy | |
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|Hyperatrophy | |
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|Contructure | |
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|Circulation | |
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|Cold | |
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|Pallor | |
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|Erethema | |
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|Cyanosis | |
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|edema | |
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|Varicosities | |
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|Positive Homan's sign | |
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|Thin shiny skin | |
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|Absence of pulse | |
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|Weak pulse | |
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|Bruit over femoral artery | |
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|D .capillary refill | |
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|Clubbing of nails | |
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|Enlarged lymph n | |
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|Movement | |
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|Paresis | |
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|Plegia | |
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|Flaccidity | |
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|Spasticity | |
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|Sensation | |
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|Hypalgesia | |
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|Analgesia | |
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|Hyperalgesia | |
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|hypoesthesia | |
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|Anesthesia | |
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|Hyperesthesia | |
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|Parasthesia | |
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|Numbness | |
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|Reflexes | |
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|Hyperreflexia | |
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|Hyporeflexia | |
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|Absent reflexes | |
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|Others:- ………………………………. Invasive devices:-………………………... | |
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|● 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 □ | |
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|Anthropometric measurements:- Weight:- ……….. Height:- …………… | |
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|Current Weight | |
|Percent ideal body weight :--------------------- X 100 = --------- X 100 = | |
|Ideal Weight | |
|Mild malnutrition □ Moderate malnutrition □ Severe malnutrition □ obesity □ | |
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|Body mass index = Weight ( in kilograms) | |
|----------------------------- = --------------------- = | |
|Height (in meters)2 | |
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|Underweight □ Overweight □ Obesity □ Extreme obesity □ | |
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|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 □ ) | |
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Abnormal results of diagnostic procedures and laboratory investigations (1 Grade)
Last Diagnostic Procedures
|Name of Procedure |Date |Result |Interpretation |
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Last Laboratory Investigations
|Name of Lab. Test |Date |Result |Normal value |Interpretation |
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Current medications & Infusions (1 Grade)
Current Medications
|Medication’s Name |Action/ |Dose |Route |Frequency |Nursing Considerations |
| |Classification | | | | |
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Current IV Infusions
|Infusion ‘s Name |Concentration |Type |Amount |Frequency |Nursing Considerations |
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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 |4 | |
| |70-89 |3 | |
| |50-69 |2 |A.......... |
| |0-49 |1 | |
| |no pulse |0 | |
|Respiratory Rate/ min |10-24 |4 |B........... |
| |25-35 |3 | |
| |> 36 |2 | |
| |1-9 |1 | |
| |none |0 | |
|Glasgow Coma Scale |Total GCS points |Points |Score |
|1- Eye opening | | | | |
| | | | | |
|- Spontaneous |4 |13-15 |4 | |
|- To voice |3 |9-12 |3 |C........... |
|- To pain |2 |6-8 |2 | |
|- None / (C) for closed eye |1 |4-5 |1 | |
| | |< 4 |0 | |
|2- Verbal response | | | | |
| | | | | |
|- Oriented |5 | | | |
|- Confused |4 | | | |
|- Inappropriate words |3 | | | |
|- Incomprehensive ward |2 | | | |
|- None / (T )for ETT \ TT |1 | | | |
|3- Motor response (response | | | | |
|to command or painful stimulus | | | | |
| | | | | |
|- Obeys commands |6 | | | |
|- Localizes pain |5 | | | |
|- Withdraw (pain) |4 | | | |
|- Flexion (pain) |3 | | | |
|- Extension (pain) |2 | | | |
|- None / (Q) for quadriplegia |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 |planning |Intervention |Evaluation |
| |diagnosis | | | |
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