NCM 118B-ZCMC-MICU

Name of Student: _________________________________

Rotation/Date/Day: ________________________________

NURSING ASSESSMENT
NURSING HISTORY
Demographic Data:
HRN: _______________ Date of Admission: ______________ Day of Admission: ______
Unit: __________ Bed #____________ Allergies: _________________________________
Age :_______ Gender :______ Marital status :________ Occupation :__________
Diagnoses:
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Reason for Hospitalization/Chief Complaints:
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History of Present illness:
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Past medical and surgical history:
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Family history:
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Life style/Psycho-socio-economic Data/Self-concept;Role-relationship;Stress-tolerance:
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 Health care pattern:
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PHYSICAL ASSESSMENT
General Appearance
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RESPIRATORY SYSTEM
AIRWAY
Patency:___________________ Airway Adjunct: ________________________
Ventilated: ETT/Tracheostomy size: ___________ position/length: ____________
BREATHING
Rate: _____________ Depth/Quality: ______________ Rhythm:___________________
Chest expansion/shape: ______________ Retractions: _______________ O2 sat: __________
Supplemental Oxygen: Device: ________________ Rate/Concentration: ________________
Breath sounds: __________________ Cough: ___________________________
Secretions/sputum (amount/characteristic):________________________________
Non-Invasive Ventilation: CPAP: Pressure: _________ FiO2: _______________
BiPAP: IPAP: ___________ EPAP: ______________
Invasive Ventilation: Mode: ________ TV: _____ BUR: _____ PEEP: ______ : FiO2: ______ PS: ____
ABG: pH: ______ PaCO2: ________ HCO3: _______ O2 sat: _______ PaO2: ________
Chest tubes (drainage): ________________
History of Symptom/s: ______________________________________________________________________
CIRCULATION (CARDIOVASCULAR/URINARY SYSTEM) FLUIDS HEMATOLOGY
BP: __________ MAP: ________ Pulse Pressure: ________ HR: _______ Heart Sounds: _____________
Pulse: rate: ________ rhythm: _______ strength: __________ Capillary refill: _______ nails: __________
Color (central/peripheral): ___________________________
Limbs (temperature/color/discoloration/swelling/venous pattern/atrophy/symmetry):
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Cardiac rhythm (ECG): _______ EF: ________ Pacemaker: ______________
Edema: ___________________ Jugular vein: ____________ CVP: _______ Skin turgor: _______________

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Skin moisture: __________________ Diaphoresis: ___________________________
Weight: gain: ________ loss: ________ Vascular Access (HD): ______________
Bleeding (amount/site): ______________________ Blood Transfusion: _______________________
Other intravascular device: __________________ Pericardiostomy: ________________________
Urine: Output/time: ____________ color: ___________ continence: _________ voiding/RUC: __________
240 Fluid balance: ________________ Fluid restriction/hydration: ________________________________
Activity tolerance: ________________________ Medications affecting CVS: _______________________
GU presenting symptoms: ______________________
History of Symptom/s: ______________________________________________________________________
DISABILITY (NEUROLOGIC/MUSCULOSKELETAL/INTEGUMENTARY SYSTEM)
LOC: ___________________ GCS: E____ V____ M____ Total: ________
Pupils :R (size/reaction) : _____________ L (size/reaction): ________________
Motor strength : Arms: R _________ L________ Legs: R__________ L: ________
Vital signs (increased ICP): BP: ______ PP: _______ PR: _______ RR: _______ Temp.:_________
Seizure: type (character): _______________________ duration: ___________ frequency:____________
Speech: ________________ Hearing: __________________ Vision: ________________
Pain (numeric pain scale/CPOT/autonomic): _______________________________
Sensation: __________________ Sedation: ______________ RASS score: _____________
Blood Glucose: __________ Mobility: ________________
Decubitus ulcer: location/s: _________________ stage: __________________
Extremities (deformities/ROM)/Body symmetry: ____________________ Wound (drains): ______________
Skin (lesion/rash/pruritus): ______________________ Eye care: ____________________
Behavior/Affect: ______________________
History of Symptom/s: ______________________________________________________________________
EXPOSURE/ENVIRONMENT/INFECTION
Central/peripheral lines (site/condition): __________________________
ETT/Tracheostomy: _________________ Stoma: _______________
NGT: ____________________ RUC: __________________ Drain: ___________________
Wound: __________________ Pressure sore: __________________ Hematoma: ___________
GASTRO-INTESTINAL SYSTEM/ABDOMEN
Mouth/tongue: abnormality/ies: _______________________ Oral care: __________________
NGT: size: _____ length: ________ Feeding type/amount/frequency: _______________________________
Abdomen (shape/tenderness/rigidity/distension/organomegaly/symmetry/color/scar):
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Bowel sound: ___________ Abdominal drain: ______________________ Colostomy: _________________
Bowel pattern: last BM: ____________ abnormality/ies: _________________________________
Diet: ____________ Dietary pattern: _____________ Supplements: ____________
Tolerance: _____________ Eating Discomforts: _______________ Swallowing: ______________________
Nausea: ________________ Vomiting: __________________
Appetite: _______________ Allergies: ________________________
Height: ____________ Weight: ____________ BMI: _______________
History of Symptom/s: _____________________________________________
OTHER ASSESSMENT DATA:

INTAKE & OUTPUT

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 Intake Output
Total Total Balance
Oral Parenteral Intake Urine/Drains BM Output

DRUG STUDY
Name of Dosage, Route, Drug Nursing Responsibilities (include side
Medication Frequency Classification/Indica effects/adverse reaction/remarks)
Generic and Brand (Rate if drip) tion (for patient)
Name

LABORATORY/DIAGNOSTIC TESTS

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 Test (Date) Results Reference Value Interpretations/Implications
HEMATOLOGY

COAGULATION TESTS

ELECTROLYTES/BLOOD CHEMISTRY

TESTS for INFECTION

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URINE/STOOL ANALYSIS

DIAGNOSTIC TESTS

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