ICU Brain 4 9 13 Aqua - Straight A Nursing
[Pages:1]Room #: Dx:
Code:
SITUATION Safety: Confused Fall Restraints Alarm Suicide Isolation: None Contact Droplet Airborne Neutropenic
Admit Date: ______ From: ______ Reason: _____________________ Tests Done Hospital Course:
BACKGROUND PMH:
MD: Allergies:
Psychosocial:
Decision Maker:
ASSESSMENT
Temperature
Neuro: 4 3 2 1
+ - NOC T-Max _____ Day T-Max _____ RASS _______ CAM
Pain
EVD Cardiac
Hemodynamics
EF: ______ Echo Date: _____________
Rhythm: _________________________
A-Line CVP Monitor Swann
Respiratory
GCS _____________________________
Clear Vent Settings ET Trach Ch T MODE ________ IS
PS ___________
Vt ____________ P/F Ratio: _____
RT ARDS
FiO2 ____________
PEEP ___________
RATE ____________
GI
GU
NG OG PEG LWS ______ Foley BSC BRP Anuric Dialysis
C-Diff: - +
Last BM: _________ NOCS
DAYS
In ______ Out______ In ______ Out ______
In ______ Out ______ In ______ Out ______
In ______ Out ______ In ______ Out ______
Diet
Fluid Balance
Muskuloskeletal
Skin
Drains
Clear Dsng: _________________
Wounds: ______________________
IV Sites PIV:
Central:
SCDs TEDs Boots Special Bed Sling Ambulating
DVT & Stress Ulcer Prophylaxis: Heparin Lovenox SCDs Pepcid Protonix
Immune System Flu: Needs Received PNA: Needs Received MRSA: Admit > 7 Days in ICU
PICC: Other:
Gtts 1) ___________________ @ ________ 2) ___________________ @ ________ 3) ___________________ @ ________ 4) ___________________ @ ________ 5) ___________________ @ ________ 6) ___________________ @ ________
Sepsis: Infection Simple Severe Lactate: __________ CVP: _______ ScVO2: ________ Abx: _____________________ Given @ :_________ Abx: _____________________ Given @: _________ Abx: _____________________ Given @: _________ Abx: _____________________ Given @:_________
Lab Draws Accu-Check:
K Parameters Mg Ph Ca
PRNs Given
7) ___________________ @ ________ Cultures: Blood x2 Urine Sputum
RECOMMENDATION / PT NEEDS
TO-DO LIST
Na: _____ ______ ______ K: _____ ______ ______ Mg: _____ ______ ______ Ca: _____ ______ ______
Ph: _____ ______ ______ Cr: _____ ______ ______
BUN: _____ ______ ______ WBC: _____ ______ ______
Hgb: _____ ______ ______ PLT: _____ ______ ______
PT: _____ ______ ______ INR: _____ ______ ______
Lactate: _____ ______ ______ HCO3: _____ ______ ______
Other:
MISC
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