CRITICAL CARE FLOW SHEET

PATIENT IDENTIFICATION
START DATE: STOP DATE:

SIGNATURE / TITLE / INITIALS

SIGNATURE / TITLE / INITIALS

TYPE:
WT Today: WT Yesterday: PAST 24 Intake Output

PA Catheter

Arterial Line

Central Line

Central Line

Sheath

Other

KG LBS

HT:

Insertion Date Insertion Site Removal Date

BALANCE 24

LAB DATA
LABWORK
TIME BS BUN Cr Na K Cl CO2 Ca Phos Magnesium Cholesterol Total Bili Alk. Phos SGOT SGPT Total Protein

RESULTS

LABWORK
Time Albumin WBC Hgb Hct PT INR PTT Platelets CPK CK - MB CPK Index Troponin Lactic Acid NH4 Pre-Albumin Digoxin

RESULTS

TIME

STAT MEDS

INITIALS

TIME

STAT MEDS

INITIALS

ISOLATION PATHWAY CODE STATUS

YES NO NO

ISOLATION TYPE: YES; If "YES", SPECIFY: DNR

NEGATIVE FLOW MAINTAINED: OTHER:

YES NO

N/A HEPAFILTER

FULL CODE

8850122 Rev. 05/05

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

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Critical Care Vital Sign Flow Sheet

HOUR 07 - 07 MINUTE :00 - :59
240 220 PULSE 200 180 160 140 120 100 BP Method A = A-Line C = Cuff 80 D = Doppler 60 40 20 0 TEMP Respirations BP Method MAP CVP PAS PAD PCWP CO/CI SVR Pulse Ox Accu-Check Radial P R/L U L Dorsalis Pedal S R/L E S R/L 200 180 160 140 120 100 80 60 40 20 0 240 220

><

BP

PULSES (Code):
Hematoma Sandbag

O = Absent

D = Doppler

1+ = Intermittent

2+ = Weak

3+ = Strong

INVASIVE LINE CARE

CHECK WHEN CHANGED
P E R I P H E R A L

CHECK WHEN CHANGED U P CHECK WHEN CHANGED U P CHECK WHEN CHANGED U P

C E N T R A L CORDIS TUBING PROX. TUBING MEDIAL TUBING DISTAL TUBING DRESSING
S W A N G A N Z

#1 DATE SITE #2 DATE SITE #3 DATE SITE

DRESSING PRESSURE TUBING FLUSH BAG CO SET TUBING

8850122 Rev. 05/05

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

A L I N E O T H E R

DRESSING PRESSURE TUBING FLUSH BAG TUBING

PAGE 2 of 6

DRUG DOSAGE (mcg/kg/min., mcg/min., etc.)

INTRAVENOUS
mcg or mg mcg or mg mcg or mg mcg or mg mcg or mg mcg or mg

DRIP WEIGHT:____________(KG)
15 16 17 18 19 20 21 22 8 Hour Total 23 24 01 02 03 04 05 06 8 Hour Total 24 Hour Total

07

08

09

10

11

12

13

14

8 Hour Total

ml

ml

ml

ml

ml

ml

PPN TPN INTRALIPIDS

BLOOD PRODUCTS I.V. MEDS

CO INJECTATE TUBE FEEDING

NG MEDS PO FLUIDS / FREE H2 O

TOTAL INTAKE
07 08 09 10 11 12 13 14 8 Hour Total 15 16 17 18 19 20 21 22 8 Hour Total 23 24 01 02 03 04 05 06 8 Hour Total 24 Hour Total

URINE
HEMODIALYSIS FLUID REMOVAL

NG STOOL DRAINS

IV SITE Q 2 Hrs CHECKS POSITION R/L/B/C

R = Right Side L = Left Side B = Back C = Chair

TOTAL OUTPUT > 1/2 < 1/2 DIET INTAKE Lunch ALL > 1/2 < 1/2 DIET INTAKE Dinner ALL > 1/2 < 1/2

DIET INTAKE Breakfast

8850122 Rev. 05/05

ALL

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

PAGE 3 of 6

NEUROLOGICAL ASSESSMENT
TIME INITIALS Size Right Reaction Size Left Reaction Please use numbers scale
B = Brisk S = Sluggish - = No Reaction C = Eye Closed

PUPILS

C O M A S C A L E

Eyes open

Best verbal response

Best motor response

Spontaneously=4 To sound=3 To pain =2 None=1 Oriented=5 Confused=4 inappropriate words=3 Incomprehensible sounds=2 None=1 Obey commands=6 Localize pain=5 Withdraws=4 Flexion to pain=3 Exten. To pain=2 None=1

Eyes closed by swelling =C Endotracheal tube or tracheostomy =T

Record best limb response

GLASCOW COMA SCALE TOTAL

E X T R E M I T Y

L E F T
R I G H T

Hand Leg Hand Leg

Consciousness
A = alert L = lethargic / drowsy R = restless C = confused CT = comatose S = stuporous / obtunded

Extremities
S = strong or normal W = weak M = slight movement A = absent or paralyzed

Consciousness Seizure Activity Speech

FALL PREVENTION STANDARD N D

Fall Standard in Use Yellow ID band on Patient Yellow Card on Door Call Light in Reach Bed Low & Locked Bed Alarm On Side Rails Up
X2 X4

PART ONE: RESTRAINT INTERVENTION E

N/A
If initial order, document time restraints applied:
MILITARY TIME

1 Indication for use of restraints:

Interference with medical treatment Risk of Falls

2 Alternative intervention(s) attempted prior to restraint applications

Nursing interventions - i.e., securing tubing, dressing Diversional activity - i.e., music, puzzles, etc. Spend more time with patients Family / significant other involvement Environment change Reduce stimuli Reality orientation Bed alarm Yes No

3 Alternative measures effective: 4 Education

Directions: Document every 2 hours (MST / CCT may complete) 1800 2000 2200 2400 0200 0400 0600

PART TWO: OBSERVATION SHEET

TIME
Hydration / Nutrition Toilet / Comfort Skin Checked ROM Circulation Checked LOC / Mental / Emotional Staff Initials

Yes No alternatives + reason(s) for restraint use: Yes No b. Patient / significant other verbalized understanding Not understood by patient; significant other unavailable

a. Patient / significant other educated on restraint

0800

1000

1200

1400

1600

5 Type & location of restraint(s) in use:

6 a.

Restraint Standard for Acute Care Setting in use:

b. Acute Confusional State Standard in use:

Yes Yes

No No

Indicate Time(s) Patient OUT OF RESTRAINTS

N D E ROUTINES & SAFETY ROUTINES & SAFETY U P SHIFT

Bed Surface M = Maxifloat S = Softcare O = Other / Specialty Bed ( Specify )

SHIFT
Back Care Bath Oral Hygiene Foley Catheter Ted / SCD / Plexiplus Lines Zeroed Activity ( BR, BRP, Chair, Ambulatory )

8850122 Rev. 05/05

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

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Peak / Mean Press Insp

RESPIRATORY TRACH / ET TUBE CM Mark

R = Right M = Middle L = Left

ABGS O2 SAT
3

Oxygen % FiO2 / LPM Tidal Volume Spontaneous TV

Vent Rate / Spont.

Vent Mode

PEEP / PS

Equipment

HOB 30

Position

paCO2

PC / IE

TIME INITIALS
C A R D I O V A S C U L A R P A C E RHYTHM H E A R T SKIN COLOR JVD EDEMA / LOCATION CAPILLARY REFILL
M A K E R

CODES
HEART SOUNDS
+

GALLOP
S

= =

S O U N D S

S1 Gallop Murmur Fx Rub

S2

S3 S4

PRESENT DECREASED S S 1 2 S

MURMUR/FRICTION RUB SKIN

+ / - = PRESENT / ABSENT = = = = = = = = WARM COOL COLD HOT DIAPHORETIC CLAMMY MOIST DRY FLUSHED NORMAL / PINK PALE CYANOTIC JAUNDICED DUSKY MOTTLED W CL CD H DI CLA M DR F N P C J D M

COLOR R/L
= = = = = = =

MODE TYPE RATE / MA RUL RML RLL LUL LLL

JVD

RESPIRATIONS
B R E A T H S O U N D S

EDEMA
N G P NP T 1+ 2+ 3+ 4+ R I S L H = = = = = = = = = = = = = =

+ / - = PRESENT / ABSENT NONE GENERALIZED PITTING NON-PITTING TRACE 2 MM PITTING 4 MM PITTING 6 MM PITTING 8 MM PITTING

R E S P I R A T O R Y

RESPIRATIONS

SUCTION SECR. COLOR AMT. C H E S T T U B E S SITE

DRAINAGE / (Describe) H2O SEAL / Bubbling +/SUCTION / (CmH2O)

BREATH SOUNDS
CL RA RH WZ E I = = = = = = = O = BR = FL D L T S F R = = = = = = =

REGULAR IRREGULAR SHALLOW LABORED HYPERVENTILATION ( RATE & DEPTH) 0* = OTHER (Asterisk & Describe) CLEAR RALES / CRACKLES RHONCHI WHEEZE EXPIRATORY INSPIRATORY DECREASED ABSENT BRONCHIAL FLAT DISTENDED LARGE TENDER SOFT FIRM RIGID

ABDOMEN BOWEL SOUNDS G STOOL: description I NG: description URINE: (color, char.) G Method of output U
COMMENTS:

ABDOMEN

BOWEL SOUNDS
= HYPOACTIVE = HYPERACTIVE O = ABSENT

+ = PRESENT

8850122 Rev. 05/05

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

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HCO3

paO2

TIME

TIME

Size

pH

PAIN MANAGEMENT
COMFORT GOAL: TIME PAIN LOCATION RATING SCALE: SEDATION PAIN RATING RATING INTERVENTION INITIALS EVALUATION TIME/PAIN # INITIALS

PAIN SCALES:
(Faces)

WONG-BAKER:

0-10 VISUAL: (Numeric) VERBAL: NON-COGNITIVE: SEDATION SCALE:

O
No Hurt

2
Hurts Little Bit

4
Hurts Little More

6
Hurts Even More

8
Hurts Whole Lot

10
Worst Pain

( FLACC Scale )

WONG-BAKER FACES PAIN SCALE from Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas PA, Whaley & Wong: Care of Infants & Children, 6th ed, St. Louis, MO: Mosby-Year Book Inc., 1999; 1153. Copyrighted by Mosby-Year Book, Inc. Reprinted with Permission.

FLACC PAIN SCALE:

S = NORMAL SLEEP, EASY TO AROUSE, ORIENTED WHEN AWAKENED, APPROPRIATE

COGNITIVE BEHAVIOR

1 = WIDE AWAKE - ALERT (OR AT BASELINE), ORIENTED, INITIATES CONVERSATION 2 = DROWSY, EASY TO AROUSE, BUT ORIENTED AND DEMONSTRATES APPROPRIATE
COGNITIVE BEHAVIOR WHEN AWAKE

3 = DROWSY, SOMEWHAT DIFFICULT TO AROUSE, BUT ORIENTED WHEN AWAKE 4 = DIFFICULT TO AROUSE, CONFUSED, NOT ORIENTED 5 = UNAROUSABLE

INTERVENTION:
1 = DISCUSS PAIN MANAGEMENT PLAN WITH PHYSICIAN 2 = PHARMACOLOGICAL (See MED KARDEX) A. Position Changed 3 = NON-PHARMACOLOGICAL

B. Relaxation Technique C. Splinting D. Imagery E. Music F. Education G. Other: ___________________________________________________

_____ = FACE Score 0 = No particular expression or smile 1 = Occasional grimace or frown, withdrawn, disinterested 2 = Frequent to constant frown, clenched jaw, quivering chin _____ = LEGS Score 0 = Normal position, or relaxed 1 = Uneasy, restless, tense 2 = Kicking, or legs drawn up _____ = ACTIVITY Score 0 = Lying quietly, normal position, moves easily 1 = Squirming, shifting back & forth, tense 2 = Arched, rigid, or jerking _____ = CRY Score 0 = No crying (asleep or awake) 1 = Moans or whimpers, occasional complaint 2 = Crying steadily, screams or sobs, frequent complaints _____ = CONSOLABILITY Score 0 = Content, relaxed 1 = Reassured by touching, hugging, talking to, distractable 2 = Difficult to console or comfort

1. Sum of FACE, LEGS, ACTIVITY, CRY & CONSOLABILITY Scores = FLACC Score 2. Record FLACC Score using the 0-10 VISUAL (NUMERIC) Scale above

SENSORY PERCEPTION
1. TOTALLY LIMITED 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO IMPAIRMENT

PRESSURE SORE RISK ASSESSMENT:

MOISTURE ACTIVITY
1. TOTALLY MOIST 2. VERY MOIST 3. OCCASIONALLY MOIST 4. RARELY MOIST 1. BEDREST 2. CHAIRFAST 3. WALKS OCCASIONALLY 4. WALKS FREQUENTLY

TO BE COMPLETED EVERY 24 HRS MOBILITY NUTRITION FRICTION & SHEAR

1. VERY POOR 2. PROBABLY INADEQUATE 3. ADEQUATE 4. EXCELLENT 1. PROBLEM 2. POTENTIAL PROBLEM 3. NO APPARENT PROBLEM

1. TOTALLY IMMOBILE 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO LIMITATIONS

SCORE:
IF TOTAL SCORE < 17, PATIENT IS AT HIGH RISK FOR PRESSURE ULCER IMPLEMENT PRESSURE ULCER PREVENTION PROTOCOL IMMEDIATELY SERUM ALBUMIN TOTAL SCORE: COMPLETED BY:

WOUND CARE:
STAGE:
I= II = III = IV =

On ADMISSION + every THURSDAY

Reddened area (intact skin) Blister, skin break Skin break exposing subcutaneous tissue Skin break exposing muscle and / or bone

WNL = R= D= M=

PERI-WOUND TISSUE:
Within Normal Limits Reddened Darkened Macerated

P = Pink / Clean S = Slough E = Eschar O = None M = Mild F = Foul APPEARANCE: ODOR: O = None S = Serous SG = Sero-sanguinous P = Purulent DRAINAGE: NA ADDITIONAL DRESSING CHANGES DOCUMENT IN PROGRESS NOTES If more than 5 wounds, use OVERLAY

(Legend)

TYPE
Venous Stasis Pressure Ulcer Traumatic Wound

SHIFT: U LOCATION: WOUND #: TYPE (Legend): TYPE: Stage: Appearance: Drainage: Odor: Peri-Wound Tissue: Size [L x W x D]# cm: Undermining [Y / N]: Nurse's Initials: Irrigation: Treatment: Time / Initials:

U WOUND #: TYPE:

U WOUND #: TYPE:

U WOUND #: TYPE:

U WOUND #: TYPE:

8850122 Rev. 02/05

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

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