It U Physician Assessment Sheet

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Name: ………………………………………………………………

MRN: …………………………………………………………….…
Sex: …………………………D.O.B.: ……………………………

ITU Physician Daily Assessment Sheet


Date/Time: ………………………… ITU Day: …………… Ceiling of Therapy: …………………………..………… DNAR: ………………

Condition: Diagnosis/Impression:

ASSESSMENT SECTION
GCS: /15 E( ) V( ) M( ) Pupils: R L
Mental State:
Motor Power: UL ( / 5) LL ( / 5)
NEURO

Pain Sites / Score: Other neurology / Imaging:

Analgesia / Sedation:

Airway: Days on NIV / IPPV:

Ventilation
RESPIRATORY

Peak TV
SpO2 FiO2 MODE PEEP
AP RR

/
ABG Date & Time
Oxygenation Ventilation Acid Base Examination CXR
PaO2/ Pa ET
PaO2
FiO2 CO2 CO2
pH HCO3 BE Ultrasound:

Secretions:
Last Vital Signs Perfusion Fingers/Toes:
HR / BP / CVP /
CRT Heart Sounds
Rhythm MAP JVP Oedema:
CARDIAC

Lactate: ScvO2:
Cardiac Output Monitoring
SV / SVR / Cardiac / vasoactive medication:
CO / CI FTC Impression / Echo
SVV SVRI

NG Fluid Balance
Input Output
Feed: NBM / PO / NG / TPN
FLUIDS / RENAL /

Crystalloid: Urine: / /
Glucose:
GI TRACT

Diuretics
Sounds: Colloid: Drains:
GAST RES:
Blood: Other:
Bowels Opened: Ultrasound:

Urinary Catheter:
Fluid Balance Yesterday
Urine Dip:

Intensive Therapy Unit


Name: …………………………………………………………………
MRN: ……………………………………………………….…….
Sex: …………………………D.O.B.: ……………………………

AST Alk P
Na+ K+ Mg2+ Ca2+ PO42- Cl- Urea Creat Alb Bili Gluc
ALT GGT
BIOCHEM / HAEM / MICRO

/ /
PT WBC Lymph
Hb Plt aPTT Fibrino. CRP T Max ºC
INR Neut Eosin

/ / /

Positive Cultures - Date / Source / Organism Line Site Day/State Keep

Antibiotic / Days / Level

Medication Review (Record Changes): Allergies:


MEDICATION

DVT Prophylaxis? If No Why?______________________________________________


BUNDLE
CARE

Head Elevation 30o? If No Why?____________________________________________


PPI / Full Enteral Nutrition? If No Why?______________________________________

Comorbidities:
PROBLEMS
ACTIVE

TARGETS Plan Comment


SpO2

PaO2
MANAGEMENT PLAN

PaCO2

MAP

pH

Urine

Fluid Bal

Temp

Glucose

Hb

K+ Mg2+

Na+ Ca2+

Date Trainee Name, Consultant Name, Nurse Name


& Time Signature & Pager Signature & Telephone Number & Signature

Intensive Therapy Unit

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