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    Emergency Room Assessment Form: Best Eye Opening Best Verbal

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    eliza marie luis
    The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

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    © All Rights Reserved
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    Emergency Room Assessment Form: Best Eye Opening Best Verbal

    Uploaded by

    eliza marie luis
    95 views2 pages
    The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

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    EMERGENCY-ROOM-ASSESSMENT-FORM

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    The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    95 views2 pages

    Emergency Room Assessment Form: Best Eye Opening Best Verbal

    Uploaded by

    eliza marie luis
    The emergency room assessment form summarizes a patient's vital signs, medical history, physical exam findings, and initial emergency care. It includes the patient's name, age, hospital number and mode of arrival. Sections document allergies, Glasgow Coma Scale, pain assessment, integumentary system, airway, breathing, lung sounds, oxygen therapy, IV therapy, OB/GYN history for women, medical management, and nursing interventions. The form is used to guide initial emergency care and transfer important medical information about the patient's condition.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    EMERGENCY ROOM ASSESSMENT FORM

    Name:________________________________________________ Age & Gender:____________


    Ward/Room:___________________________________________ Hospital Number:___________
    Date:________ Time:_________ Mode of Arrival:____________ Triage Category:__________________
    ALLERGIES: ___________________________________

    Glasgow Coma Scale


    Best Eye (4) - Spontaneous (2) - To pain
    Opening (3) - To voice (1) – None

    Best (5)- Oriented (Coos, babbles) (2)- Incompatible Sounds


    Verbal (4)- Confused (Cries) (1)- None
    (3)- Inappropriate Words
    (Scream/grunts)

    Pain Scale ( 0 1 2 3 4 5 6 7 8 9 10 )
    Location:_________________________
    Quality:__________________________
    Radiating at:______________________
    Duration:________________________
    How the pain started?:______________________

    Integumentary
    ( ) Warm to touch ( ) Cold, Clammy
    ( ) Cyanotic ( ) Diaphoretic
    ( ) Pale ( ) Dry
    ( ) Jaundice ( ) Others:_______________

    Airway
    ( ) Patent Airway
    ( ) Impaired Airway

    Breathing
    ( ) Normal ( ) Deep
    ( ) Labored ( ) Nasal Flaring
    ( ) Shallow ( ) Chest Retractions
    Others:_____________________________________

    Lung Sounds Oxygen Theraphy


    RL LL Method: ____________________________
    __ Clear __ Liters/minute:________________________
    __ Wheezes __ Time Started:_________________________
    __ Stridor __ ET size:______________________________
    __ Diminished __ Level:_______________________________
    __ Pleural Rub __
    __ Crackles __
    Intravenous Therapy
    Main Line
    IVF:_________________________
    Medicine Added:______________
    Flow Rate:___________________
    Date:_______________________

    Side Drip/s
    IVF:________________________ IVF:________________________
    Medicine Added:_____________ Medicine Added:_____________
    Flow Rate:___________________ Flow Rate:___________________
    Date:_______________________ Date:_______________________

    OB/GYN Medical Management


    ( ) Active Labor ( ) Suturing
    LMP:_________________ ( ) Cast Application
    EDC:_________________ ( ) CTT
    FHT:_________________ FH:______________ ( ) Paracentesis
    IE:___________________ ( ) Others:____________________
    Gravida:_________ Para:___________
    AOG:________________
    Bag of Water:___________
    Discharge:______________

    Nursing Interventions
    ( ) Warm Compress ( ) TSB
    ( ) Cold Compress ( ) Irrigation
    ( ) Dressing Applied ( ) Positioning:______________________________
    ( ) Splint Applied ( ) Others:_________________________________
    ( ) Wound Cleaning

    Other ASSESSMENT/S:
    _____________________________________________________________________________________
    _____________________________________________________________________________________

    Other CONTRAPTIONS/NURSING INTERVENTIONS:


    _____________________________________________________________________________________
    _____________________________________________________________________________________

    Test VS before transfer: BP:______ PR:______ RR:_______ T:_______ Pain Scale:________

    Completed by:_______________________________

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