Taibah University ‫جامعة طيبة‬

Al-Madinah Al-Munawara ‫المدينة المنورة‬

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الباطنة والجراحة‬

ASSESSMENT DATA FORM - EMERGENCY NURSING

Student Name: ___________________________ Year Level & Group:__________
Affiliating Hospital: _______________________________ Date:_____________

I. Patient's Demographic Data

IDK AT
Patient Name: __________________________________
Nationality:_____________________________ Gender:______________ Age: _________
Occupation: ______________________________________ Marital Status: ____________

Date of arrival:
Mode of arrival___________________ 9Am
Time of Arrival________ _____

Triage category: ______________________

Information Source: Red Patient Family Records
013
PE iscomplaing of1 frequent
II. Chief Complaints:________________________________________________________________
vomitingchestpain
_____________________________________________________________________________
andhe had an epigastri pain 2 w beforeadmission

DM FTN CKD DiagnosedwithESRDbutrequiresMDsto

Present Illness:_______________________________________________________________________________________
confirm n
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

III. Pre-Hospital Treatment:  NA  If present

 O2 L/min/  IV: cannula size  Backboard

 NC  NRB  Ambu L R  Long  Short  KED
 Airway  Medications  Scoop
 Oral  Nasal  Other  Bilateral Head Supports
 ET tube cm  C-Collar on: Yes No  Splint on
 Ice on
 CPR started at (time)  Dressing on
 Other ________________

1
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الباطنة والجراحة‬

Initial Assessment
AIRWAY DISABILITY
 Patent
 Oral Airway
Gool  Suctioning Glasgow Coma Score
Eye Opening
AVPU
 Bag Mask
 Nasal Airway  O2 ______L. Spontaneously 4
Alert
 ET
 Tracheostomy
 Comments _________
Nasalcanalais To Speech (Shout)
To Pain 0
3
2
 Cricothyroidotomy establishedtosupportoxygenation No Response 1

BREATHING Verbal Response

R L
Spontaneous
 Normal
Respiratory Effort Oriented (Coos, Babbles)
Confused 054
at Lung soundscomrades  Shallow  Nasal flaring (Consolable, Cry)
Clear  Stridor  Tachypnea Inappropriate Words 3 Verbal
Rales  Dyspnea  Grunting (Persistent Cries, Screams)
Rhonchi/Wheezes  Retracting  Absent Incomprehensible 2
Decreased  Intercostal  Paradoxical Words (Grunts, Restless)
Absent  Substernal  Cough No Responses 1
Smoker  Yes  No  Unk Motor Pain _____

Capillary Refill:
CIRCULATION dubbedfingers
 None  Delayed (> 2 sec)  Normal (< 2 sec)
Obeys (Spontaneous)
Localized Pain O65
Pulses Present:  Carotid Femoral  Radial  Pedal Withdrawal to Pain 4
Palpated Pulse:  Regular  Irregular Flexion to Pain 3
Unresponsive

F
Heart Sounds:  Audible  Absent (Decorticate)
Jugular Vein Distension:  No  Yes Extension to Pain 2
Bleeding:
Skin Color:
 Controlled  Uncontrolled
 Dusky
 NAr No Response to Pain 1
 Pink
 Pallor
 Flushed
 Cyanotic
 Mottled
Total GCS Score u
____

Area of Injury

NRA
Allergies:

Procedures
Time Procedure Results
ET Tube Combitube Size
Secured @ cm
NA
Central Line/ IV
FiO2
Size
%
Fr

l
Site
NA
Warming Measures
Solution
 Fluids
 Mechanical

NA
 Blankets
I
NG Tube Size
NA
Foley / Quick Cath
Color
Size 1 A = Abrasion Fc = Closed OW = Open

Neck immobilization
NA Color
Before admission B = Burns
Fracture
Fd = Dislocation
Wound
P = Paralysis
C-Collar Applied:

na
After admission
I C = Crepitus
D = Deformity
Fo = Open Fracture
L = Laceration
S = Edema
Ta = Total
Amputation
Splinting Location: E = Ecchymosis Na = Near

I I
Amputation

2
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الباطنة والجراحة‬

Secondary Assessment
Head/Scalp Eyes Mouth Ears
 Intact  Rash  PEARL  Intact  No drainage

I
 Laceration  Burns  Raccoon eyes  Teeth Discolonaitt  Drainage
 Abrasions  Pain  Oval  Missing teeth  Right  Left
 Bruising  Battle  Visual Acuity  Dentures intact  Clear  Clear
Signs  Comments  Blood  Clear

Neck Chest Heart Sounds

 Intact  C-Collar  Symmetrical rChest Pain u
 Present
 Swelling  Pain  Asymmetrical Location  Distant
 Trachea midline  Paradoxical movement Time of onset  Absent
 Trachea deviated Location Activity @ onset
 Sub-q emphysema  Crepitus  Flail chest
 Difficulty swallowing Location  Other
Abdomen / Pelvis / GU
Abdomen Bowel Sounds Pelvis
 Soft  Distended  Last Intake:  Present 
a Intact
 Nontender  Rigid Food  Absent  Pain
 Tender Liquid  Hyperactive
 Comments:  Hypoactive  Blood at meatus
fat Abdomen  Blood at rectum
 Instability
Posterior Extremities
 Intact  Intact
 Deformity  Fracture
 Pain  Pain
 Comments  Deformity
 Comments

Pupil Reaction Pain Scale Comments

Tem S-slow U-unequal 0-10
P R BP SaO2 O2
Time B-brisk D-dilated Pain
p L/min F-fixed = - Equal
C-closed by swelling Scale Type
gam 370 85benimeem 170170mm
/ 85 Right Left
/ 6110evestpain
/
/
/
/
/
/
/
/
/
/
Medications Given
Medication Dose Route Time Given Initials
Lasix 120mg In 932am
omepromote womb so Am
sofran guy IV so am
NS 250mi v
I
Regularinsulin s Ion sa
3
 Taibah University ‫جامعة طيبة‬
Al-Madinah Al-Munawara ‫المدينة المنورة‬
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
College of Nursing ‫كلية التمريض‬
Medical Surgical Department ‫قسم الباطنة والجراحة‬

Input Output
Source Prior to Arrival ED Total Source Prior to Arrival ED Total
IV Fluids Urine
Emesis

si 111
Chest Tube
Other

Blood
Fresh Frozen Plasma

Past Health History: (includes previous illness, hospitalizations, surgeries & other management):
_______________________________________________________________________________________________
MGH CES RD
_______________________________________________________________________________________________
_______________________________________________________________________________________________
___________________________________

Past Medications ______________________________________________________

_______________________________________________________________________________________________
I
_________________________________________________________________

Family History: __________________________________________________________________

_______________________________________________________________________________________________
_________________________________________________________________
________________________________________________________________________________

Lifestyle Pattern:_________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Nurse Notes:

ABG FE left
pts no Agh O na Bo troponin
Coz l abc 6 K s areas s
ca
Hcossiz pets
m