Inaia Medical College (IMC) Critical health nursing/practice,

2019/2020
(Nur 458 )

Assessment Sheet
Critical
Care (ICU
)
Date of documentation:12/10/2021
Student name:.....................................................Student ID

Patient name: Alia Salim Age: 75

Hospital number:……………………………… Sex: female
Date of admission: 12/10/2021 Level of education: primary school
Stay period: 8 days Occupation: house wife
Marital status: marred

Present History:
-Diagnosis/ Present illness: end stage renal disease and heart failure
-Chief complaints on admission: end stage kidney disease for dialysis
-Associated signs and symptoms:…………………………………………………………
-Onset / Duration / Frequency:……………………………………………………………
-Predisposing factors:…………………………………………………………………….
-Reliving measures and its effect:……………………………………………………….
Past History:
 Medical:
-Diagnosis / Duration: hypertention, DM
-Diagnosis / Duration:…………………………………………………………………….
 Surgical:
-Name of surgery / Duration:……………………………………………………………..
-Name of surgery / Duration:……………………………………………………………..
Allergy History: unknown allergic
Family history:
-Diagnosis / Relation: free family history
1
-Diagnosis / Relation:……………………………………………………………………

Continue
Ite 1s Related nursing
ms t diagnosis
Respiratory # Abnormal
Pattern:-
-Irregular
-Labored
-Dyspneic
-Tachypneic 

# Couch:-
-Productive 

Normal -Non Productive

# Secretions:-
-Clear
-Yellow
-Green
-Blood-tinged
-Thin
-Thick
# Need for Suction:-
-Yes
-No 

# Need for
Oxygen
Therapy:
-Room air
-Nasal cannula
-Mask
Normal -Non-Rebreather
-Endotracheal tube
-Tracheostomy
# Chest Tube:
Cardiovascular *Comparative
Related nursing
Peripheral
diagnosis
Pulse:
Peripheral Pulse Right radial pulse
scale:-
Zero: Absent pulse Left radial pulse +3
+1:Thready pulse Right pedal pulse +3
+2:Weak pulse Left pedal pulse +3
+3:Normale pulse
+4Boundeng pulse *Capillary refill ↑ 3
seconds
Normal Yes 

No
*Edema:-
- Generalized
-Localized 

Neurological # Glasgow 1st Related nursing diagnosis

coma scale:-
Eyes open:
.Spontaneously:(4) 

Normal .To speech:(3)

.To Pain:(2)
.No response:(1)
.Untestable:(U)

Ite 1s Related nursing diagnosis

ms t
Best verbal:
.Oriented:(5) 

.Confused:(4)
.Inappropriate ward:(3)
.
Incomprehensibl
e sounds:(2)
.No response:(1)
.Untestable:(U)
Best motor response:
.Obey commands (6) 

.Localized pain (5)

.Flexion to pain (4)
.Decorticate (3
.Decerbrate (2)
.No response (1)
.Untestable (U)
Total score: 15
# Pupils Rt / Lt
-Fixed
-Pinpoint
-Sluggish
 -Unequal
# Convulsion
Gastrointestinal *Eating
abnormalitie
s:-
-Difficulty chewing:
-Difficulty
swallowing:
Normal -
Swallowin
g
precaution
:
*Tenderness of
abdomen
*Nausea
*Vomiting:
*Bowel Sound: 1
st

-Hypoactive
-Hyperactive
Integument # Skin Condition:-
ry (Skin)
-Cold and clammy
Normal -Hot and dry
# Color: -Pale
-Flushed
-Jaundiced
-Cyanotic
# Turgor: -Fair
-Sluggish
-poor
# Skin Rash
Pressure Ulcer:- -Site # 1
………………..
Normal -Site # 2
………………...
-Site # 3
………………...
 -Site # 4
………………...
Continue
Ite 1 Related nursing diagnosis
ms st
Stoma *Specify
site:…………….
*Appearance:
-Pink:
-Necrotic:
Wound *Specify
site:…………….
*Wound
appearanc
e:-
-Clean closed wound
-Clean opened wound
-Septic wound
# Abnormal Related nursing
Muscloskeletal diagnosis
findings of limbs:-
Risk for fall related to unsteady gait
-Extremity weakness
(paresis)
-Unsteady gait 

Muscloskeletal 1 Related nursing

st diagnosis
-Contracture of joint
-Paresthesia
-Paralysis
-Amputee
# Assisstive Device:-
-Wheelchair/walker 

-Cane/Crutches
-Prosthesis
# Traction:-
-Skin traction:
-Skeletal Traction
# Cast
Related nursing
Urinary *Abnormal diagnosis
Findings:
On regular ( ESKD) -Incontinent
-Hematuria
 -Dysuria
-Urgency
-Urinary Catheter
Psychological # Psychological Related nursing
diagnosis
Inaia Medical College (IMC) Critical health nursing/practice,
2019/2020
(Nur 458 )

Abnormal Findings:
.Anxious 

.Flat affect Anxiety related to medical condition

.Combative
.Suicide precaution
Activities of daily *Feeding Related nursing diagnosis
l-iIvnidnegpendent *Bathing
(3)
-Need assistance *Dressing
(-D2)ependant (1) *Toileting
*Transferring
*Walking

Assessment of
Pain:
Date Location Intensity Frequency Duration
chest 5/10 intermitted 30 second
12/10 /2021

Diagnostic
Measures: # Lab
investigation:

Lab Results Normal Ranges Comment

Investigation
CBC:
Hb 13.1 12.0-17.0% Normal
Normal
RBC 6.4 3.8-4.8 ml/ul Normal
WBC 8.7 4.0-10.0 thou/ul
PLT 188x103/mm3 150-390 NORMAL
NEUTRO 68% 40-70% High
Na 131 mmOl/L
135-145 mmOl/L Normal

albumin 4.2 3.7-5.4 gm% Normal

globulin 1.9 1.8 – 3.6 gm % Normal
SGOT 20 5-40 IU normal
SGPT 25 5-30 IU Normal
Inaia Medical College (IMC) Critical health nursing/practice,
2019/2020
(Nur 458 )
Lipid profile 60mg% 25-50mg%
Total cholesterol 200mg% High
Serum triglyceride 250 mg% High
LDL 136 mg % High
HDL 38 mg% Low
VLDL 46 mg% Normal
K 3.0 mmOl/L 3.5-5.5 mmOl/L normal
Inaia Medical College (IMC) Critical health nursing/practice,
2019/2020
(Nur 458 )

# Radiological
examination:

Type of examination Resul

ts
x- RAY NORMAL

Instructor’s signature: …………………………..

Student’s signature: ………………………......