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    It U Physician Assessment Sheet

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    Carlos Jorge
    This document contains a daily assessment sheet for a patient in an Intensive Therapy Unit (ITU). It includes sections to record the patient's vital signs, neurological and respiratory assessments, cardiac function, fluid balance, biochemistry results, active medications and management plan. The assessment indicates the patient requires intubation and ventilation support based on their low SpO2 and abnormal blood gas results. Their condition is critically ill based on the multiple organ system assessments recorded.

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    It U Physician Assessment Sheet

    Uploaded by

    Carlos Jorge
    55 views2 pages
    This document contains a daily assessment sheet for a patient in an Intensive Therapy Unit (ITU). It includes sections to record the patient's vital signs, neurological and respiratory assessments, cardiac function, fluid balance, biochemistry results, active medications and management plan. The assessment indicates the patient requires intubation and ventilation support based on their low SpO2 and abnormal blood gas results. Their condition is critically ill based on the multiple organ system assessments recorded.

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    It u Physician Assessment Sheet

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    This document contains a daily assessment sheet for a patient in an Intensive Therapy Unit (ITU). It includes sections to record the patient's vital signs, neurological and respiratory assessments, cardiac function, fluid balance, biochemistry results, active medications and management plan. The assessment indicates the patient requires intubation and ventilation support based on their low SpO2 and abnormal blood gas results. Their condition is critically ill based on the multiple organ system assessments recorded.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    55 views2 pages

    It U Physician Assessment Sheet

    Uploaded by

    Carlos Jorge
    This document contains a daily assessment sheet for a patient in an Intensive Therapy Unit (ITU). It includes sections to record the patient's vital signs, neurological and respiratory assessments, cardiac function, fluid balance, biochemistry results, active medications and management plan. The assessment indicates the patient requires intubation and ventilation support based on their low SpO2 and abnormal blood gas results. Their condition is critically ill based on the multiple organ system assessments recorded.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 2

    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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