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Arizona State University

College of Nursing & Healthcare Innovation
Critical Care Assessment Form
Student Name:

Date:

Patient age:

Gender:

Code Status:

Medical Power of Attorney: (relationship only)

Marital status:

Days since admission:

Allergies:
Reason for/course of this admission:

Medical Diagnosis/es:

Pathophysiology:

Pertinent surgery/procedures completed since admission:

Past Medical History: (including events leading to this hospitalization)

Current data and interventions/therapies

Activity/Exercise (Respiration/Circulation)
CardiovascularHeart Rate and Sounds, ECG rhythm, hemodynamic parameters:

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HEMODYNAMIC CALCULATIONS
NORMS

770-1500 DS/cm5
100-250 DS/cm5

2.5-4.0 l/min/m2
41-51
1970-2390 DSm2/cm5
225-315 DSm2/cm5
3.4-4.2 kg-m/m2
50-62 g-m/m2
0.54-0.66 kg-m/m2
7.9-9.7 g-m/m2

C.O.
HR
ABPs
ABPd
ABPm
PAPs
PAPd
PAPm
PAWP
CVPm
BSA
SV
SVR
PVR
LCW
LVSW
RCW
RVSW
C.I.
SI
SVRI
PVRI
LCWI
LVSWI
RCWI
RVSWI

Date

Date

Date

Explanation

(no wedge used; use PAPd)

RespiratoryBreath Sounds (ventilator settings, ABGs)

Activity Tolerance/Self care (Use of Restraints?)

Nutrition/Metabolic
Height:
Weight:
Temperature for past 24 hours:
Intake:
Diet/Fluid Restriction/Tube feeding:
Actual intake -mode, amount, safety concerns, labs (electrolytes):
Oral intake:
Medication infusions:
TOTAL =
Mouth and Skin integrity/Hygiene:
Output: (24 hours)
Urine:
JP Drains:
NG:
TOTAL:

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Elimination
Gastrointestinal elimination:
Abdomen:
Bowel sounds:
Last BM:
Voids:
Tubes:
Lab Values (attach Lab Values worksheet)
Abnormal lab results and interpretation:

Cognitive/Perceptual
Pain and Pain Control measures:

LOC/Motor Response:

Sleep/Rest

Self Perception, Values, Coping, Sexuality, Role/Relationship, Health Perception/Mgmt.