ICU GUIDE to Charting by

SYSTEMFRANCE ELLYSONCAROL MONETTE

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time;LOC: awake, alert, confused, agitated, lethargic, unresponsive;Behavior/Mood: pleasant, cooperative, anxious, withdrawn, sad, combative,Speech: verbal, non-verbal, slurred, language barrier, aphasic, receptive, expressive, pupils size, shape, reaction to light, Vision: diplopia,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 dressingDressings: drains, incisions, sutures/staples, drainage (amount, color, consistency, odor)

PAIN

Site of pain, quality, severity, pain score, analgesia response

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

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

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

GENITURINAL SYSTEM

Bladder distension, continent, incontinent, catheter, condom catheter, retention, urgency, dysuria, urgency, urine, color, clarity, odor, output

INTEGUMENT

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

SOCIAL

Significant other, family, social support, family meeting