QUICK HEAD TO TOE ASSESSMENT FOR CRITICAL CARE NURSES

  1. Neurological:

a. Status: GCS, Pupils, Orientation, Response to commands

b.Sedation & Analgesia: Medication/Last dose

C. Sedation Score: Richmond Agitation and Sedation Score (RASS)

d.Delirium Score: CAM-ICU

  1. Respiratory:

a. Respiratory Rate, Pattern, Air entry, Added sounds, SpO₂.

b. Secretions: Mucoid/Purulent; +/++/+++

C. Mechanical Ventilator: Modes/PS/PEEP/FiO₂

d. ABG: pH/pCO,/pO,/HCO, FiO2

e. Tracheostomy: Concern

3. Cardiovascular System:

a. Temperature: Febrile / Afebrile / Tmax

b. HR; Rhythm: Normal / Abnormal

C. Blood Pressure

d. Vasopressor / Ionotropes: Current dose, change in dose

e. Active Arrhythmias, ongoing treatment

4. Gastrointestinal System (GI):

a. Feeding: OG/NG/Type/Quantity/Calorie

b. Bowel Sound: Present / Sluggish / Absent

C. Bowel motion/Stool: Type/Number/ Abnormal

d. TPN: Type/Rate/Target Rate/Total Calorie

  1. Genitourinary System (GU)/ Metabolic:

a. Urine output: per hour

b. Total Fluid Intake (TFI = IV+NG/OG+ Meds) per hour

C. Total Intake/Output (Last 24 hour)

d. Cumulative Fluid Balance (Since ICU Admission)

  1. Vascular Access:

a. Catheters: Central Venous/ Vascular Catheters/Dialysis Catheters

b. Peripheral Lines

C. Arterial Lines: Sites, Functioning

d.Drains: Site/Type/Days/Output

  1. Skin:

a. Intact or presence of Bruise, Blisters, Abrasions: Site, Type

b. Surgical Incision: Location, Look (Clean, Healthy, Unhealthy, Infected) Bed sore (Braden Score)

  1. Any other issues:

a. Patients/Family/ Socioeconomic / Affordability

Nepali Nurse

Nepali Nurse,RN,BSN

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