UNIVERSITY OF VIRGINIA HEALTH SYSTEM

CRITICAL CARE SYSTEMS ASSESSMENT BURN CENTER

Date :

Time :

Neurological
Anesthetized / Sedated but arousable / Awake / Alert / Lethargic / Obtunded / Comatose
Oriented :

x1

x2

x3

Follow commands Yes

Perria Other
Restraint :

Disoriented : occ / freq / totally

% time / No

Protective Reflexes : None / Cough / Gag / Blink

UE

LE

Strong / Weak

None

Movement : R UE none / purposeful / nonpurposeful R LE none/purposeful/nonpurposeful

L UE none / purposeful / nonpurposeful L LE none/purposeful/nonpurposeful
Strength : R UE Str / mod / weak L UE Str / mod / weak
R LE Str / mod / weak L LE Str / mod / weak
Sensation : R UE Impact / Impaired L UE Impact / Impaired
R LE Impact / Impaired L LE Impact / Impaired
Comments :
Pain Assessment
Is the patient currently having pain ? Yes / No If yes, complete below :
Patient able to communicate ? Yes / No

pain inferred by nonverbals / alteration in vital signs

Location / radiation of pain :

Pain rating :

Associated signs / symptoms / behaviours :

Onset / duration :

Any aggravating or alleviating factors ?

Intervention planned / performed :

Patients pain goal :

( Note any side effect, changes in pain quality / rating, and si/sx/behaviours on flow sheet as
appropriate )
Respiratory
ETT # /
Ventilator :

/
FI02

cm @
IMV

Spontaneous Respirations : None

FT

NC

PEEP

CPAP

Shallow Deep

Room air
AC

Unlabored

Trach #
PS

PIP

Symmetrical/Asymmetrical

Breath sounds : Right

Left

Clear

Bases Decreased

Rales

Rhonchi Wheezes

Clear

Bases Decreased

Rales

Rhonchi Wheezes

Airway : Sx / Sputum

none / small / mod / large thin / thick / frothy

Clear / white / yellow / tan / bloody / carbonaceous

Cough : Productive / Non productive
Pleur-Evac

Pleural tube : Rx

Lx

-20cm Sx / Str drain

Drainage : Serosanguinous / Serous / None

Air Leak : Yes / No

Comments :
Cardiovascular
NSR

SBrady

STach

AFib

AFlutter

PVC Unifocal / Multi-focal rare / occ / freq

S1S2 : Clear

Distant

Muffled

S3 S4

Paced

Other :

PAC / PNC : rare / occ / freq

Rub

Murmur

Click

Other :

Skin : R UE warm/cool/cold dry/clammy/diaph pale/pink/cyan cap refill

sec edema -

L UE warm/cool/cold dry/clammy/diaph pale/pink/cyan cap refill

sec edema -

R LE warm/cool/cold dry/clammy/diaph pale/pink/cyan cap refill

sec edema -

L LE warm/cool/cold dry/clammy/diaph pale/pink/cyan cap refill

sec edema -

Edema :

Face / Neck

Pulse ( 0 4+ )

Extremities

Radial R

General
DP R

PT R

Comments : See CCFS for vital signs, hemodynamic profiles, and lab result
IV Fluids : ( Rate, Dose, Infusion Port, Site concentration )
Gastrointestinal :
Soft / Firm

Distended / Nondistended

Bowel Sounds : None / hypo / active / hyper

NGT/OGT: LCS/Drain/Clamped
Return: None/Irrigant only/clear/green/tan/coffe ground/bloody
Nausea / Emesis :

NPO / ICE / clear liq / Full liq

TF :

Strength :

Diet :

Rate :

Comments :
Genitourinary :
Foley / Condom / Catheter to st drain Spont void Continent / incontinent
Urine : Straw / yellow / amber / bloody

clear / cloudy Sediment : white / dark

Irrigation :
Comments :
Integumentary :
Breakdown / Pressure sore
Ecchymosis
Dressings / Incision
JP SITE
Ace Wrap: R

Bulb Sx / Drain
LE

SCD/TED Hose : R

Drainage : None/Serousangious/Serous

LE
LE

LE

Knee/Thigh High

Eggcrate

Geo-matt

Kin-Air

Sheepskin Other
Comments :
Psychosocial :
Invasive Lines/ wounds / dressings : invasive lines patent ; sites free of six of infection ; dressings
dry & intact ; distal ports of pressure lines transduced to standard heparin flush with good wave
form, unless otherwise noted.
PA cath @

cm