Assessment Sheet

Student Name:---------------------------------------------------------------------------------
Pt Name:-------------------------------------- Code ---------- Date-------------------------- DM □ HTN □ HCV □
Dx ---------------------------------------------------------------- Section ---------------------- IHD □ CVA □ HBV □

Vital Signs Diabetic Therapy Record

Time

Acetone in
Pulse A-line Type of
Temp HR RR Cuff MAP CVP CBG Dose route site urine
Oxy Sys/dys Insulin

Cardiac
IV fluids Blood products Nutrition Total Intake
Infusions
P
PRBC F
Hourly Running L Hourly Running
Time

Whole F Total TPN PO

Total Total T Total Total
Blood P
S

Output Ventilation
Urine Chest NG Total Output
Time

Hourly Running Mode Rate Fio2 TV Peep Ps

/hr Total 1) 2) Total /hr Total
Total Total

Total Balance= --------------------------------------------------------------------------------

Patient Name:- ……………………………………… Date:- …………………… Section…………………

Injury □ Abdomen: Soft □ Firm □

Pain / discomfort R/t □ Tender □ Distended □
Anxiety Free –mild anxiety □ Last BM: …………….…………….…………….…………….

GIT
Anxiety High □ Bowel sound:
General

Insomnia □ Hyperactive □ Hypoactive □ Absent □ Active □

Calm Cooperative □ Nausea or Vomiting □
Angry Demanding Combative □ Diet: …………….…………….…………….……………. …...
Agitated Depressed □ NPO □
Daily activities: Dependent □ Independent □ Urine :
Patient / Family Coping W/illness □ Clear □ Cloudy □ Color: …………….

Urinary
Patient / Family Coping W/treatment □ Incontinent □ Urgency □ Dysuria □
Heart Sound Retention □ Polyuria □
No Murmur □ Voiding Freely □
Murmur □ Indwelling Urinary Catheter □
Capillary Refill < 3 Sec □ Date: ……………. Size: ……………. Type: …………….
Peripheral / Dependent Edema □ Skin:
Generalized Edema □ Cool □ Warm □ Hot □
Moist □ Dry □ Flushed □
Pulse: (+) Present (–) Absent Jaundice □ Pale □ Cyanotic □
Cardiovascular

Rt Lt Oral Mucosa: Moist □ Dry □

Radial Turgor: Fair □ Poor □
Brachial No Impairment Of Skin □
Femoral Skin lesions □ Rash □ Petechiae □
Popliteal Ecchymosis □
Dorsalis Pedis Others:- ……………………………………………………..
Posterior Tibial Pressure Ulcer: □ Circle And Number

VASCULAR ACCESS / TUBES

INSERT SIZE
Site SITE COND.
DATE TYPE

Integumentary
Room Air □
O2 Treatment:
Nasal canula □ Face mask □ Tracheostomy □
ETT □ Size……………. Level ………... Number
Breath Sound:
Clear = Cl Color
Respiratory

Fine Crackles = Fcr U Length

Coarse Crackles = Ccr Width
Wheezes = W Drainage
Diminished=D Stage
Absent= A
Cough: None □ Nonproductive □ Productive □ Stages:
Dyspnea □ 1 – Red Area, Non Blanchable
Secretions: 2- Blisters, Skin Break, Or Tears
Large □ Moderate □ Small □ 3- Exposed Subcutaneous Tissue
Consistency 4-Exposed Muscle or Bone
Thin □ Thick □ Frothy □
Bloody □ Yellow □ Green □
White □ Brown □
 Special Instructions:-
Degree of Edema

Pain Rating Scale

EYES VERBAL MOTOR

Pupil Scale Spontaneously
To Speech
4
3
Oriented
Confused (Time , Place )
5
4
Obeys Commands
Localize Pain
6
5
1 2 3 4 5 6 7 8 To Pain 2 Inappropriate Speech 3 Flexion Withdrawl 4
No eye Opening 1 Vocalizes 2 Abnormal Flexion 3
        No Vocalization 1 Abnormal Extension 2
Areflexic 1

ABG Neurological Assessment

Result Interpretation GCS Pupils

………………
Time

O2 Eyes Best Best

Site

Ph Pco2 Po2 Hco3 Na+ K+ Total Rt Lt

Sat ……………… Opening Verbal Motor
………………
………………
………………
………………
………………
………………
Radiological Examinations:-
Procedure Result

Lab Investigations:-
Test Result Normal range

Medications:-
Name Route Dose Frequency
Patient problems in form of Nursing Diagnosis:-
1) …………………………………………………………………………………………
Actual Problems

2) …………………………………………………………………………………………

3) …………………………………………………………………………………………
4) …………………………………………………………………………………………

5) …………………………………………………………………………………………

1)………………………………………………………………………………………….
Potential Problems

2) …………………………………………………………………………………………
3) …………………………………………………………………………………………

4) …………………………………………………………………………………………

5) …………………………………………………………………………………………

Nursing Notes:-

Time Keyword Interventions

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