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ICU GUIDE to Charting by SYSTEM

ICU GUIDE to Charting by SYSTEM. FRANCE ELLYSON CAROL MONETTE. CNS. Orientation : person, place, time ; LOC : awake, alert, confused, agitated, lethargic, unresponsive ; Behavior /Mood : pleasant, cooperative, anxious, withdrawn, sad, combative ,

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ICU GUIDE to Charting by SYSTEM

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  1. ICU GUIDE to Charting by SYSTEM FRANCE ELLYSON CAROL MONETTE

  2. CNS Orientation: person, place, time; LOC: awake, alert, confused, agitated, lethargic, unresponsive; Behavior/Mood: pleasant, cooperative, anxious, withdrawn, sad, combative, Speech: verbal, non-verbal, slurred, language barrier, aphasic, receptive, expressive, pupils size, shape, reaction to light, Vision: diplopia, nystagmus, hemianopia, Hearing: hearing aids, Cranial nerve deficits: EVD: level order, drainage or monitor, CSF fluctuation, color, clarity, amount, waveform on monitor, EVD dressing Dressings: drains, incisions, sutures/staples, drainage (amount, color, consistency, odor)

  3. PAIN Site of pain, quality, severity, pain score, analgesia response

  4. RESPIRATORY SYSTEM Spontaneous, rhythm, depth, dyspnea, shortness of breath, cough; productive/non-productive, sputum; color, consistency, frequency of suctioning, breath sounds, ventilated: mode, FiO2, ETCO2, rate

  5. CARDIOVASULAR SYSTEM Cardiac monitor, rhythm, CVAD, (P) IV sites, IV solutions, rate, dressings, sites, Body Temp, BP, arterial lines, Swan-Ganz catheter, C.O., C.I., wedge, Temp to touch, moisture, edema, pitting, non-pitting, capillary refill, peripheral pulses, TED stockings, SCD machine

  6. GASTROINTESTINAL SYSTEM Presence of bowel sounds, RLQ, RUQ, LUQ, LLQ, normoactive, hypoactive, hyperactive, soft, distended, firm, non-distended, flat, round, obese, NG, PEG, PEJ, NPO, DAT, feeding, solution, rate, intermittent, continuous, gastric residual, date of last BM, continent, incontinent, color, consistency, amount, weight, height, glucose control

  7. GENITURINAL SYSTEM Bladder distension, continent, incontinent, catheter, condom catheter, retention, urgency, dysuria, urgency, urine, color, clarity, odor, output

  8. INTEGUMENT Color, Temp, diaphoresis, dry, rash, oral cavity, pressure ulcer, location, stage, dressing

  9. SOCIAL Significant other, family, social support, family meeting

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