Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
5Activity
0 of .
Results for:
No results containing your search query
P. 1
Critical Care Nursing Assessment Form - Copy

Critical Care Nursing Assessment Form - Copy

Ratings: (0)|Views: 1,297|Likes:
Published by Prajatiya Harwoko

More info:

Published by: Prajatiya Harwoko on Feb 01, 2012
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

02/25/2015

pdf

text

original

 
NORTH COAST AREA HEALTH SERVICE
CRITICAL CARE NURSING ASSESSMENT FORM
ATTACH Patient I.D LABELSafety Check:
r
Resus.bag
r
Suction & correct setup
r
Alarms & limits
r
Bed rails
r
U.P.S (vent/crrt/monitor)
r
I.D band
r
Review manual handling form
 
   N  e  u  r  o   l  o  g   i  c  a   l
r
See Critical Care Flow Chart for Neurological Assessment & Sedation/Analgesia Infusions
Mental Status: ___________________________________________________________________________________________________________________________________________________________________________________________GCS: Eye_____ Verbal_____ Motor_____ Pupils: L(mm)____ R(mm)____ Reaction L_____ R _____Restraints:
r
Upper extremities
r
Lower extremitiesPain:
r
Denies
r
Present
r
Unable to assess due to __________Gag reex:
r
resent
r
sent
   R  e  s  p   i  r  a   t  o  r  y
r
See Critical Care Flow Chart for Oxygen Therapy & Ventilator Settings
 Airway:
r
Maintains Own
r
BiPAP /CPAP
r
ETT: Size : _______ Length at teeth/gums _______cm Cuff pressure: _______cm/H20
r
Tracheostomy: size: _______Oral Mucosa:
r
Intact
r
Other*Lip Condition:
r
Intact
r
Other*racea stoma: escre: _______________________Cough:
r
Spontaneous
r
Stimulated by suctioning
r
Strong
r
Moderate
r
Weak
r
AbsentRespirations:
r
Ventilated
r
N.I.V
r
Non-ventilated 
r
Easy/Regular
r
eep
r
Shallow
r
Laboured
r
Intercostal use
r
Other *Chest Expansion:
r
Symmetrical
r
Asymmetrical 
r
Paradoxical
r
Tracheal tugracea:
r
ne
r
Deviated left
r
evate rgtOther (description)___________________________________________________________________________________
r
Chest tube #1 to: _____________________________
r
Suction ______ cm H2O
r
nerwater sea onyOscillation:
r
Present
r
Absent Air Leak:
r
Present
r
AbsentDrainage: _______________________________________S/C emphysema:
r
resent
r
sent
r
Chest tube #2 to: ____________________________
r
Suction ______ cm H2O
r
nerwater sea onyOscillation:
r
Present
r
Absent Air Leak:
r
Present
r
AbsentDrainage: ______________________________________S/C emphysema:
r
resent
r
sent
   C  a  r   d   i  o  v  a  s  c  u   l  a  r
r
See Critical Care Flow Chart for Vital Signs, Haemodynamics, and Neurovascular Assessment
ECG: Lead: _____ Rate: _____ PR: _____ QRS: _____ QT: _____ ST Segment: _____ T wave _____Interpretation: _________________________________________________________________________Skin (peripheral):
r
Pink
r
Pale
r
Jaundiced
r
Flushed
r
Mottled
r
Cyanotic
r
Diaphoretic
r
Cold
r
Cool
r
ot
r
arm
r
ry
r
ostOedema:
r
Generalised
r
Localised to: ______________________________(sacral, ankle etc)
   E   C   G   S   t  r   i  p  s
 Rhythm Strip/ Haemodynamic Wave Forms
PASTE STRIP HEREBreathSounds
ear
 
D DecreasedW WheezesFC FineCrep’s X CoarseCrep’s A AbsentB BronchialI InspiratoryE Expiratory
 CRI  I   C CRN UR S I  N G S  S  S  S MN ORM
 

Activity (5)

You've already reviewed this. Edit your review.
crystal liked this
1 thousand reads
1 hundred reads

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->