Critical Care Nursing Assessment Form - Copy

NORTH COAST AREA HEALTH SERVICE ATTACH Patient I.D LABEL

CRITICAL CARE NURSING  ASSESSMENT FORM Safety Check:

r Resus.bag r Suction & correct setup

r Alarms & limits r Bed rails

(vent/crrt/monitor) itor) r I.D band r U.P.S (vent/crrt/mon r

r Review manual handling form

See Critical Care Flow Chart for Neurological Assessment & Sedation/Analgesia Infusions

Mental Status: _______________________________________________________________________________________

   l   a   c ____________________________________________________________________________________________________    i   g   o GCS: Eye_____ Verbal_____ Motor_____ Pupils: L(mm)____ R(mm)____    l Reaction L_____ R _____   o   r   u Restraints: r Upper extremities r Lower extremities   e    N

Pain:

r Denies

r Present

Gag reex: r resent

r

r Unable to assess due to __________

sent

r See Critical Care Flow Chart for Oxygen Therapy & Ventilator Settings

 Airway: r Maintains Own ETT:: r ETT

r BiPAP /CPAP

Size : _______

Length at teeth/gums _______cm

r Tracheostomy: size: _______

Oral Mucosa:

r Intact

r Other*

Lip Condition:

r Intact

r Other*

rac ea sto stoma ma::

r Stimulated by suctioning

r Strong r Moderate

Respirations:   y   r   o    t   a   r    i   p   s   e    R Chest Expansion:

Breath Sounds

escrr e: ___ esc ______ _____ _____ ______ _____ _____ ______ ____ _

Cough: r Spontaneous

Cuff pressure: _______cm/H20

r Weak

r Absent

r Ventilated

r N.I.V

r Non-ventilated

r Easy/Regular

r

r Shallow

eep

ear D Decreased W Wheezes FC Fine Crep’s   X Coarse Crep’s   A Absent B Bronchial

 C r Laboured r Intercostal use r Other * R I   T  r Symmetrical r Asymmetrical I Inspiratory I    C E Expiratory r Paradoxical r Tracheal tug A  L  rac ea: r ne ate r g t r Deviated left r ev at Other (description)___________________________________________________________________________________  C A  R _____________________________ _____________ ____________________________ _____________ r Chest tube #1 to: ________________ r Chest tube #2 to: _______________ E  rwa ater se sea on y r Suction ______ cm H2O erw wate terr sea on y N r Suction ______ cm H2O r n erw r n er  U Oscillation: r Present r Absent Oscillation: r Present r Absent R  Air Leak:  Air Leak: r Present r Absent r Present r Absent  S  I   N Drainage: _______________________________________ Drainage: ______________________________________  G S/C emphysema: r resent r sent S/C emphysema: r resent r sent A   S  See Critical Care Flow Chart for Vital Signs, Haemodynamics, and Neurovascular Assessment r  S    r   a ECG: Lead: _____ Rate: _____ PR: _____ QRS: _____ QT:    l E  QT: _____ ST Segment: _____ T wave _____   u  S    c   s Interpretation: _________________________________________________________________________  S    a   v M   o Skin (peripheral): r Pink r Pale r Jaundiced r Flushed r Mottled r Cyanotic r Diaphoretic    i E     d   r   a r Cold r Cool r ot r arm r ry r o st N    C T  Oedema: r Generalised r Localised to: ______________________________(sacral, ankle etc) F   O  Rhythm Strip/ Haemodynamic Wave Forms R M   s   p    i   r    t    S    G    C    E

PASTE STRIP HERE

1 

r See Critical Care Flow Chart for Rate/Type of Enteral Feeding and TPN r Soft r Obese Bowel Sounds: r  Absent r orma

 Abdomen:

r NBM

Diet:

r r r r

Firm r Flat r Rounded Distended r Guarding r Rebound Tenderness Present ncrease r ecrease

r CF r FF r Diet r Diabetic r Cardiac r Tube feeds

____________________________ r Special Consistency: ____________________________   a   n    i    t   s   n   e    t   n    i   o   r    t   s   a    G

r Other*

Feeding Tube:

Type: ________________

Insitu to: __________( L/R nare, mouth etc.)

Insertion site:

r Gastric r uo ena r Intact r Other*

r e una by: ___________________________ r Placement veried by:

r  Administering Feeds

r Clamped

r  Aspirated q4h r Straight drainage

Description of aspirate: __________________________________________________ ____________________________________________________ __ Other (description)

____________________________________________________ ______________________________________________ ______

r Prior to admission

Last BM: _____/_____

Stool:

+++ Incision

Stool colour: ________________Stool characteristic: __________ ype:: ___ ______ ______ ______ ____ _ r Type

Ostomy: om na

ype: e: __ ____ ____ ____ ____ ____ ___ _ ra n: r yp

Appear App earanc ance e of Sto Stoma: ma: ___ ______ ______ _____ __ ocat oc at on: __ ____ ____ ____ ____ ____ ___ _

ru s ng > Stab Site O Ostomy

Drainage (describe): __________________________________   y   r   a   n    i   r   u   o    t    i   n   e    G

ra n

r See Critical Care Flow Chart for Urine Output, Fluid Balance, & CRRT Monitoring (description)____________________________________ _____ Catheter: r Type: _____ Size: _________Urine (description)_______________________________ Urethral/vaginal Urethral/va ginal discharge: r Describe: ________________________________

r Menstruating

Concentrations, & Rates r See Critical Care Flow Chart for Drugs, Infusions, Concentrations,

r CVC:

r  Arterial Line/ PICCO:

# Lumens ______ Location: _________________

Location: ____________________________________

r Patent r Heparin lock r Other* Flush Bag: r ormal saline r ressurised and adequate uid r us e an ne trans uce Lumen’s:

  s   s   e   c   c    A   r   a    l   u   c   s   a    V

Site:

r

o redness/swelling

r Other*

Dressing:

r

&I *(describe)______________

Flush Bag

r Normal saline r Pressurised and adequate uid r us e an ne trans uce

Site:

r No redness/swelling

Dressing:

r D&I *(describe)______________

r Other*

r PIV #1:

r Other line

Location: _______________________________

Type: ___________ Location: __________________

Site:

r

ress ng ress ng:: *(describe)

r

o redness/swelling

r Other*

Site:

r No redness/swelling

r Other*

ress ng ress ng:: r *(describe)

r See Critical Care Flow Chart for Position, Hygiene & activity     l   a    t   e    l   e    k   s   o    l   u   c   s   u    M    &    t   n   e   m   u   g   e    t   n    I

Skin Condition (general)_______________________________________ (general)_______________________________________ (L) (R) (L) (R) Sacrum intact r marked r

eels intact r marked r

r

broken r

broken r

r at ent to e pos t one

-

r

r

Elbows intact r marked r

r

broken r

r

r

egrees ea up

unless contraindicat contraindicated ed

r Calf Compressor Device Date:___ / ___/____ Time:

r TEDS

ress re ss ng r, Drain X, Splint //// 

Name:_____________________ Signature: _____________________