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ICU Brain Useful Report Organizing tool Includes items most relevant to ICU nursing To organize patient data when doing a rotation in the ICU as a nursing student
Typology: Study notes
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Date of Admission: Date of Care: HPI/Course of Hospitalization (Inc. surgery): PMH:/PSH Code Status: GOALS: Neuro: Labs ABG: Time pH PaO2 PaCO2 HCO3- (^) SaO2 / Interpretation Cardiovascular: Respiratory: Gastrointestinal: B L D NPO Diet/Feeding Route: Last BM: Genitourinary: Peri care Foley Skin: Turn:7/9/11/13/15/17/19/ Photos Diagnostics: IV Lines: Location: Type: Running: Location: Type: Running: Location: Type: Running: Family/Spiritual/Cultural Needs or Issues: Drains: (chest tubes, ventriculostomy, surg drain) Location: Output: Location: Output:
Vital Signs (Every ____ Hours) Time BP HR/Rhythm O2 Sat RR Temp Pain Medications Due Due Due Due Pain/Sedation Management Medication & Freq Time Administered Time Administered Time Administered Blood Glucose Checks (Every ____ Hours) Intake and Output Time Level Action