ICU Nursing Report Sheet

• Patient Name

• Room #
  Address

• Conducted on

  Date

• Prepared by

General Information

• Admit date

  Date

• Reason

• Situation:

• Safety

  Select Confused Fall Restraints Alarm Suicide Other

  • Confused
  • Fall
  • Restraints
  • Alarm
  • Suicide
  • Other

• Please provide more details

• Isolation

  Select None Contact Droplet Airborne Neutropenic

  • None
  • Contact
  • Droplet
  • Airborne
  • Neutropenic

• Background:

• PMH

• Psychosocial

• Decision Maker

Temperature

• NOC T-Max

• Day T-Max

Neuro

• Neuro

  4

  3

  2

  1

• EVD

  ✔

  ✖

• RASS

• CAM

  +

  -

• GCS

Cardiac

• EF

• Rhythm

• Echo date

  Date

Hemodynamics

• Hemodynamics equipment

  A-line

  CVP Monitor

  Swann

Respiratory

• Condition

  Clear

  ET

  Trach

  Ch T

  IS

• P/F Ratio

Vent Settings

• Settings

  RT

  ARDS

GI

• Procedure

  NG

  OG

  PEG

  LWS

• C-Diff

  -

  +

• Diet

GU

• Procedure

  Foley

  BSC

  BRP

  Anuric

  Dialysis

• NOCS:

• In

  Date

• Out

  Date

• DAYS:

• In

  Date

• Out

  Date

• Fluid Balance

Muskuloskelatal

• Condition

  Select SCDs Boots Sling TEDs Special Bed Ambulating

  • SCDs
  • Boots
  • Sling
  • TEDs
  • Special Bed
  • Ambulating

Skin

• Condition

  Clear

  Dsng

  Wounds

• Specify details

DVT & Stress Ulcer Prophylaxis

• Procedure

  Select Heparin Lovenox SCDs Pepcid Protonix

  • Heparin
  • Lovenox
  • SCDs
  • Pepcid
  • Protonix

Drains

• Please provide details

Immune System

• Flu

  Needs

  Received

• PNA

  Needs

  Received

• MRSA

  Admit

  > 7 Days in ICU

IV Sites

• IV Site

  PIV

  Central

  PICC

  Other

• Please specify

Gtts

• Please enter details

Sepsis

• Sepsis

  Infection

  Simple

  Severe

• Lactate

• CVP

• ScVO2

• Click + to add Abx

Item

• Abx

• Given at

• Cultures

  Blood X2

  Urine

  Sputum

Lab Draws

• Lab Draws

  K

  Mg

  Ph

  Ca

• Accu-Check

• Parameters

• PRNs Given

Recommendation/PT Needs

• Please provide your recommedations

Completion

• Full Name and Signature of Nurse Attendee

  Sign