NURSING ASSESSMENT FORM (NICU)

Name: .................................................................................Age: ........Sex: M F Folder No:………………..

Date and Time:…………………………………………. Shift:………………………………………………….
RESPIRATION Respirations: Regular Unlabored Irregular Labored
Breath Sounds: Right ( Clear Rales) Left ( Clear Rales) Shortness of Breath: No Yes
(indicate triggers) …………………………………….. Respiration………….bpm SPO₂………….%
Respiratory Treatments: None Oxygen Aerosol/Nebulizer CPAP/BIPAP
CIRCULATION Pulse: Regular Irregular Skin: Pink Cyanotic Pale Mottled Warm
Cool Dry Diaphoretic Edema: No Yes Pitting: No Yes Pulse……….bpm
NEUROLOGICAL Sensation: Intact Diminished/Absent Pain: None Yes Site of pain and
cause of pain………………………………………………………. Seizures: No Yes
GC Scale: Eye opening (E) …… Motor response(M) ……Verbal response(V) ……. Score…………
SKIN Normal Pale Jaundice Red Rash Irritation Abrasion Other Temp………. °C
Skin Intact: Yes No Special Care or Monitoring: No Yes Cord: Clean Dry Moist
MUSCULOSKELETAL ROM: Full Limited Tremors
NUTRITION Diet: NPO NG\OG NCS Gastrostomy/Jejunostomy tube Parenteral Nutrition
Breast feeding/Breast milk Other type of formula…………………….Recent wgt change: No Yes
Conditions affecting suckling or swallowing: No Yes Monitoring required at mealtimes: No Yes
Fluids Monitoring: No Yes Increased Restricted
Mucous membranes: Moist Dry Skin turgor: Good Fair Poor
ELIMINATION Bowel sounds present: Yes No Stool: No Yes
Urine Yes No Constipation Yes No
NURSE NAME AND SIGNATURE:……………………………………………………………………………..

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HANDING OVER NURSE………………………………………………………………………………………….