Name of Student: ID.
No: Date of Assignment: Unit:
Initial of Patient: Age: Diagnosis Surgery done with date:
History of Present Illness (DOA/complaints/admission/initial treatments/ significant events till now)
Past Medical History (onset/treatment)
Personal and Social Health History
Treatment (dose/
Physical Assessment Diagnostics frequency) Diagnostic Label
MRI/ CT/EEG report
CNS
ABG:
ph pCO2 pO2 HC03 Lac
ph pCO2 pO2 HC03 Lac
RS
CXR:
Sputum culture:
RBC: Platelet: WBC: Hb:
RBC: Platelet: WBC: Hb:
N L E M B N
L E M B
CVS
INR: PT: APTT: TT: Fib
INR: PT: APTT: TT: Fib
Cardiac enzyme:
ECHO:
Albumin: Protein:
Albumin: Protein:
RBS: RBS:
GI
Others (specify):
Na: Cl: Mg: PO4: K:
Na: Cl: Mg: PO4: K:
GU
Urea: Creat: GFR:
Urea: Creat: GFR:
Culture:
SKIN
Xray (bone/joint):
MS
EENT/
Immunolog CRP: ESR:
CRP: ESR:
y
SOCIAL
PSYCH
O-
Significant Observations Tubes and Lines
7 8 9 10 11 12 7 8 9 10 11 12 Tubings/Lines Date Inserted Date to be Changed
Color ETT/Trache Tube
Chest Movement Arterial Line
Apex CVC
Air entry
Base EVD line
Pressure area care NGT/ PEG line
Abdomen Urinary Catheter
Bladder Peripheral Line
Bowel sounds Dialysis Line
Bowels Blood Line/Type
ET secretions Mech. Vent. Line
Position Health Education Plan Based on the Priority Nursing Diagnosis
Eye Care Recognize complication(s)
Catheter Care
Mouth Care
Home care considerations for prescribed treatment
Physio- Chest
therapy
Limbs
Chest Tracheal Secretions
Color Air Entry Pressure Area Care Abdomen Bladder Bowel Sounds Bowels Position Physio Pupils
Movement Quantity Quality Color
Perfused ✓ Adequate ✓ Coarse Creps C Wall Perfused V Soft S Palpable P Heard ✓ Open ✓ Small S Loose L White W Right R Done ✓ Reaction +
Pale P Decreased ↓ Fine Creps F Reddened R Firm F Unpalpable✗ Unheard ✗ Not Open ✗ Medium M Tenacious T Yellow Y Left L Not Done ✗ No reaction -
Cyanosed C Absent ✗ Wheeze W Edematous E Distended D Large L Bloody B Prone P
Passed Flatus F Sluggish Reaction
Jaundice J Broken B Guarding G Green G Supine S
Monitoring 7 8 9 10 11 12 7 8 9 10 11 12 Medications 7 8 9 10 11 12 7 8 9 10 11 12
41 41
Inotrope
40 40
39 39
38 38
Sedative/ Analgesic
MEDICATION DOSAGE (unit/hour)
37 37
36 36
35 35
Neuro Blockers
34 34
33 240 240 33
32 200 200 32 Antibiotic
31 180 180 31
Other
30 160 160 30
BP. RR: BLUE/BLACK HR, TEMPERATURE: RED CVP: GREEN
29 140 140 29
120 120 Intake 7 8 9 10 11 12 7 8 9 10 11 12
100 100
Drug Infusions (ml/hr)
80 80
60 60
40 40
30 30
Flush
28 28
26 26
IV Fluids
22 22
20 20
GI
18 18
16 16 Hourly Intake
Cum. Total
14 14 Output
Urine
12 12 Drains
Drains
10 10 N/G
Hourly Output
8 8 Cum. Total
Hourly balance
6 6 PREVIOUS BALANCE PREVIOUS BALANCE
Significant Observations 7 8 9 10 11 12 7 8 9 10 11 12
4 4
CPOT
2 2 GCS/FS
ETT/TT size&Cuff pres
0 0 ETCO2
RBS/Reflow
-2 -2 Pupil Size L/R
RASS Score/ Any other
Ventilator Settings 7 8 9 10 11 12 7 8 9 10 11 12 Pacemaker
Mode A rate / output
Set/ Actual V rate / output
Freq
IE Ratio CRITICAL CARE PAIN OBSERVATION TOOL FOUR SCORE
T.vol
Vol
Minute Vol. Relaxed 0 Eyelids open, tracking or blinking to command 4
Eye Response
Inspiratory Facial Expression Tense 1 Eyelids open but not tracking 3
PEEP Grimacing 2 Eyelids closed, opens to loud noise 2
Pressure
ASB/PS Absent 0 Eyelids closed, opens to pain 1
FIO2 Body Movement Protection 1 Eyelids remain closed to pain 0
O2 Therapy Restless 2 Thumbs up, fist, or peace sign to command 4
Response
SpO2 Relaxed 0 Localizing pain 3
Motor
ABG 7 8 9 10 11 12 7 8 9 10 11 12 Muscle Tension Tense 1 Flexion response to pain 2
Ph Rigid 2 Extensor posturing 1
Ventilator
pCO2 Intubated Patients Tolerating 0 No response to pain/ generalized myoclonus 0
Complian
pO2 Coughing 1 Pupil and corneal reflexes present 4
ce
Brainstem
HCO3 Fighting 2 One pupil wide and fixed 3
Reflexes
SaO2 Extubated Patients Normal 0 Pupil or corneal reflexes absent 2
Vocalisatio
Intracaranial Pres. Moaning 1 Pupil and corneal reflexes absent 1
Art.BP/PAP/PCWP Crying out 2 Absent pupil, corneal and cough reflexes 0
n
Mean Arterial Pres. Richmond Agitation &Sedation Scale Not intubated, regular breathing pattern 4
Respiration
Cerebral P.Presure 4 Combative 1 Drowzy Not intubated, Cheyne-Stokes breathing pattern 3
IABP 7 8 9 10 11 12 7 8 9 10 11 12 3 Very Agitated 2 Light sedation Not intubated, irregular breathing pattern 2
Frequency 2 Agitated 3 Mod. sedation Breathes above ventilator rate 1
Augmentation 1 Restless 4 Deep sedation Breathes at ventilator rate or apnea 0
0 Alert & Calm 5 Unarousable
Critical Care Nursing by :E.C.Mirafuentes RN,MAN Critical Care Nursing/ Clinicals
