Page 25 - AACN Essentials of Critical-Care Nursing Pocket Handbook, Second Edition
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Assessment Parameters Contour of abdomen Position of drainage tubes Color and amount of secretions Bilirubin and albumin values Electrolyte and glucose values CBC and coagulation values WBC with differential count Color and temperature of skin
• Bowel sounds • • • • Fluid balance • • • Temperature • • • • • • • • • • • • Sleep patterns •
Body System Gastrointestinal Endocrine, hematologic, and immunologic Integumentary Pain/discomfort Psychosocial
Ongoing Assessment Template Assessment Parameters Pupils Motor strength of extremities Blood pressure Heart rate and rhythm Heart sounds Capillary refill Peripheral pulses Patency of IVs Verification of IV solutions and medications Hemodynami
Body System LOC • • • • Cardiovascular • • • • • • • • • Respiratory • • • • • • • •
2.4 Nervous Renal
