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.) | |

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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 □ ………………………………………... |

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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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|● 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) | |

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|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:- | |

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|● 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 | | | | |

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|- 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 | | | | |

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|- 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 | | | | |

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|- Obeys commands |6 | | | |

|- Localizes pain |5 | | | |

|- Withdraw (pain) |4 | | | |

|- Flexion (pain) |3 | | | |

|- Extension (pain) |2 | | | |

|- None / (Q) for quadriplegia |1 | | | |

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|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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