"Pink Icu Brain Sheet Template"

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