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  • St. John ICU Report

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    This document contains a patient chart with sections for patient vitals, medical history, exam findings, test results, treatment plan, and medications. Key information includes the patient's isolation requirements, weight, neurological and respiratory exam findings, vital signs, allergies, medical issues and devices, lab results, skin assessment, planned treatments including compression devices and positioning, and scheduled and PRN medications. The chart has space to document assessments and orders for two separate time periods.

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    This document contains a patient chart with sections for patient vitals, medical history, exam findings, test results, treatment plan, and medications. Key information includes the patient's isolation requirements, weight, neurological and respiratory exam findings, vital signs, allergies, medical issues and devices, lab results, skin assessment, planned treatments including compression devices and positioning, and scheduled and PRN medications. The chart has space to document assessments and orders for two separate time periods.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    100 views2 pages

    St. John ICU Report

    Uploaded by

    bounced
    This document contains a patient chart with sections for patient vitals, medical history, exam findings, test results, treatment plan, and medications. Key information includes the patient's isolation requirements, weight, neurological and respiratory exam findings, vital signs, allergies, medical issues and devices, lab results, skin assessment, planned treatments including compression devices and positioning, and scheduled and PRN medications. The chart has space to document assessments and orders for two separate time periods.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    of 2

    □Full Code □DNR □Meds □DNI □Full Code □DNR □Meds □DNI

    Isolation:__________________ Isolation:__________________
    Weight:_________ Weight:_________
    Physicians: Physicians:
    Neuro: □WNL □Sedated Neuro: □WNL □Sedated
    □Unresponsive □Confused □Unresponsive □Confused

    T:____P:_____R:_____BP:_______ T:____P:_____R:_____BP:_______
    Allergies: □EVD@_______cm □Open □Clamped Allergies: □EVD@_______cm □Open □Clamped
    Pulmonary: □WNL □NC L Pulmonary: □WNL □NC L
    □ETT # @ cm@lip □CASS □ETT # @ cm@lip □CASS
    PMH: □HTN □COPD □CAD □Trache # Shiley Bivona PMH: □HTN □COPD □CAD □Trache # Shiley Bivona
    □CHF □DM □CHF □DM
    BiPap ___/___ ___% BiPap ___/___ ___%
    Mode: Rate: Mode: Rate:
    FiO2: PS: FiO2: PS:
    TV: PEEP: TV: PEEP:
    Lung Sounds: Lung Sounds:
    HPI Admitted__________ HPI Admitted__________

    Cardiac: □WNL □Murmur □Edema Cardiac: □WNL □Murmur □Edema


    Rhythm: Rhythm:

    Tests/Diagnostics PP: Tests/Diagnostics PP:


    GI/GU: □WNL □Foley □NG LCS/LIS GI/GU: □WNL □Foley □NG LCS/LIS
    □Diet: □TF: □Diet: □TF:

    pH____pCO2____pO2____HCO3____ pH____pCO2____pO2____HCO3____
    BUN/Cr_________ K______ Mg_____ BUN/Cr_________ K______ Mg_____
    H/H_______ WBC______ Plt_______ H/H_______ WBC______ Plt_______
    Skin: □WNL □Restraints Activity: Skin: □WNL □Restraints Activity:
    Plan: Plan:
    □SCD’S □Plexis TED’s □SCD’S □Plexis TED’s

    PRN’s: Edema: PRN’s: Edema:


    IV: IV:

    Med Dose Rate Med Dose Rate


    08 14 08 14
    09 15 09 15
    10 16 10 16
    11 17 11 17
    12 18 12 18
    13 19 13 19
    □Full Code □DNR □Meds □DNI □Full Code □DNR □Meds □DNI
    Isolation:__________________ Isolation:__________________
    Weight:_________ Weight:_________

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