REVISION: 8/08
GUIDELINE APPROVAL: 8/08
TITLE:
GUIDELINE FOR COMPLETTION OF THE 24 HOUR ICU PATIENT FLOW SHEET
INSTRUCTIONS:
The Adult Patient Profile (APP) must be completed within 24 hours of admission. The biophysical assessment MUST be completed
within 1 hour for ICU/Intermediate Care admissions. (See Policy Standard,
GENERAL INFORMATION
Definition of symbols:
( √ ) Indicates that the
standard has been met with no deviations. This symbol
may also represent the activity was done.
( * ) Indicates
that there was an abnormal finding or deviation from the UAMS
standard, protocol, or procedure. A focus note must be written.
( g ) Indicates that the standard or change has continued.
( ∆ ) Indicates that an IV site or wound dressing has been changed.
At the top of each column the initials of the
caregiver and military time of observation will be documented. The symbols listed above are charted in the
large box in each column under the initial and time of observation.
Any area that does not
apply to the patient should have the notation “N/A” for not applicable.
Blank lines on the form may be used for charting
any extra information needed to cover specific protocols, guidelines or
physicians orders.
Patient Medical Records label should be placed in
the upper left hand corner of every page.
TITLE PAGE (page 1)
To be completed by the shift leaving at 0700.
1. Document
Today’s date. Please note: All pages of document MUST be dated.
2. Document
Post Operative Date if applicable.
3. Document
Today’s weight.
4. Document
the previous day’s weight.
5. Document
dry weight.
6. Document
maximum temperature for current flow sheet.
7. Document the 24 hour total Urine,
8. Document
the 24 hour total Intake and Output totals for current flow sheet.
9. Document
the 24 hour total Intake and Output for previous day’s flow sheet.
10. Document
the patient’s wearing an ID band.
11. Document
if applicable the patient’s wearing a High Risk Band and /or Allergy Band.
13. Document
or transfer documentation of all locations, types and dates of Vascular Access.
14. Document or transfer documentation of
urinary catheter and date of placement or discontinuance.
15. Document the initials then signature
and title of all personnel who provide patient care.
16. All personnel will print legibly their
name next to their signature.
CHARTING KEY’S (pages 2
and 3)
Accepted
ICU abbreviations to be used throughout the flow sheet.
The
Comfort Assessment in the Absence of Self Report
Mental
Status Codes
Level
of Pain
Level
of Sedation
Riker
Sedation – Agitation Scale
Temperature Route Key
IV
/ Invasive Lines / Injection Site Key
Fall
Risk Screening Tool
Oral
Care / Hygiene Key
Braden
Scale
Turn
Key
BIOPHYSICAL
ASSESSEMENT (page 4)
To
be completed by a Licensed Nurse. Refer
to “Biophysical Assessment Standards for the
Adult
Patient” (Addendum I.1C)
1. Document the initials and time of
assessment.
KEYPOINT: Documentation is by deviation from standards as defined in the Protocol for Biophysical Assessment of the Adult Patient. Any variation from this standards results in a notation of ( * ) in the box and a corresponding focus note. Assessment is performed according to unit specific policy addenda and with a change in the caregiver. The RN must document the initial assessment on the 24 hour flow sheet.
2. Neurological/EENT: Specific neurological findings will be
documented on the vital signs sheet e.g. Glasgow Coma Scale. Mental status must be assessed every 2 hours if the patient is restrained
and documented on the Restraints section of the flow sheet.
3. Cardiovascular: Specific hemodynamic
monitoring will be documented on the vital signs sheet.
KEYPOINT: If a patient
requires frequent neurovascular checks use the 24 Hour Neurovascular Check
Sheet (MR 406) to document findings.
4. Respiratory: The number of degrees the head of bed
is elevated will be documented in the small box every four hours.
5. Gastrointestinal:
6. Genitourinary:
7. Integumentary: Each element of the Braden Score will be scored
separately on the lines indicated on page 3, and the total Braden Score will be documented each
shift on the lines indicated on page 4.
8. Musculoskeletal: Each element of the Falls Risk Score will be scored
separately on the lines indicated on page 3, and the total for The Falls Risk Score will be documented
each shift on the lines indicated on page 4.
9. Psychosocial:
10. Pain Score: Enter the pain score as stated or
indicated by the patient every four hours or with any complaints.
11. Level of Sedation: Enter the letter indicative of scale used
and sedation level every four hours or in association with any
reassessment.
KEYPOINT: Use the “Level of Sedation” scale for
the extubated
patient and “Riker Sedation – Agitation Scale” for the intubated patient.
PAIN
COMFORT ASSESSMENT (page 4)
Section
1 -3 to be completed when the patient is unable to state or indicate a pain
score, document
every four hours or with any changes in
intravenous pain medications. Numbers 4
– 5 to be
completed on all patients.
1. Unable to report due to: Choose a letter/letters from the “Comfort
Assessment in the Absence of Self Report” key which apply to the patient.
2. Assume pain present due to: Same as above. Note: If “other” - document ( O * ) and indicate specifics in focus note.
3. Exhibiting pain behaviors: Same as above.
4. Interventions: Document “P” for pharmacological interventions or “NP” for nonpharmacological interventions
(e.g. Repositioning)
5. Reassessment time: Document the next reassessment as needed
if an intervention was done with the current assessment. An additional Biophysical Assessment will be
completed with entries in the Pain Assessment, Level of Sedation and Pain
Comfort Assessment section at that time.
“R” for resolved or “U” for unresolved will be document in
the lower half of the box at this time.
Documenting a “U” will
require further intervention and reassessment.
EPIDURAL
/ PCA (page 4)
Circle
either epidural or PCA which every may be applicable to the patient. Refer to
“Protocol
for the Management of the Patient Receiving Temporary Epidural/Intrathecal
Analgesia”
(Protocol 7).
1. LOP/LOS: Document the patient’s LOP/LOS, pain as
stated by the patient in the first box and level of sedation per the key in the
second box.
2. Drug & Conc.: Document the drug being administered and
the concentration below heading “Epidural
/ PCA”.
3. Dose: Continuous/Bolus: Document continuous dose ordered in the
first box and bolus (PCA) dose ordered in the second box.
4. Lockout/4 Hour Limit: Document the lock out time ordered by
physician in the first box and the 4 hour limit ordered in the second box.
5. Total Cont / Total Bolus: At the end of the shift, document in the
first box under 1700 the total continuous dose and in the second box the total
bolus dose (PCA).
6. Time / Initials: Document the time and initials of all
assessments and any changes in pump settings.
KEYPOINT: PCA initiation,
change in settings or waste require verification by two licensed personal and should be indicated with a ( * ) and a corresponding entry made in
the “High Risk Drug” section (page
6) of the flow sheet.
PLAN
OF CARE (page 5)
List
of Protocols in effect for current flow sheet.
1. List of Protocols: List protocols that are in effect.
2. Implemented: Date the protocol was implemented.
3. Outcomes Met: Date outcomes were met and protocol
discontinued. Note: If discontinued does not require transfer to
new flow sheet
KEYPOINT: Protocol
Lists are to be reviewed and either discontinued or transferred to the new 24
hour flow sheet by the shift leaving at 0700.
Any shift may initiate and or discontinue a protocol as needed.
INITIAL PAIN ASSESSMENT (page 5)
Must be completed within the first 24 hours of admission for every patient.
1. Time: Indicate the time (military) the note is written.
2. Initial Pain
Assessment: Check yes or no for initial pain assessment.
3. If this is the initial assessment, the information related to location, onset, duration, frequency, and relieved by must be answered.
FOCUS
NOTE (page 5 and 6)
All
notes may be initialed at the end of entry.
1. Time: Indicate the time (military) the note is
written.
2. Note ID: Indicate area of flow sheet where the
deviation from the standard occurred. (e.g. Biophysical
Assessment, Vital Signs, etc.)
3. Briefly write any notes required to
note deviations to standards or miscellaneous entries.
HIGH
RISK DRUGS (page 6)
Refer
to “Administration of High Risk Drugs” (Addendum J.23)
1. List the name of the high risk
drug and time verified by two licensed personal.
2. Place the initial’s of each
licensed personal.
ACTIVITIES
OF DAILY LIVING (page 7)
This
section addresses patient care. Document
time and initial in the large box. In
the
small box document ( √
) if done or meets standard,
( * ) to indicate inability to tolerate
or comply with activity, and enter description
in focus note, unless otherwise instructed.
1. Safety: Refer to “ICU Documentation Standard”
(Addendum I.1a)
2. Equipment: Refer to “ICU Documentation Standard” (
3. Diet: Next to the word “Diet” document type of
diet e.g. “Regular”. If on a calorie count circle the word and write in the calorie count
ordered.
In the large box write % of diet
taken. Small boxes have B = Breakfast, L
= Lunch, and D = Dinner. The larger box
is used to document snacks, time and % taken.
4. Oral Care / Hygiene: In the large box place the number or
numbers corresponding to the types of hygiene given, refer to Oral Care /
Hygiene Key (page 3).
5. Activity: Under word “Activity” document activity the physician ordered e.g. “BR – bed
rest, BSC – Bedside commode, OOB TID”.
In the small box use ( out ) to indicate the
when patient was up and ( in ) when patient put back to bed.
6. Turn every 2 hrs: In the small box document the positioning
of the patient. Refer to the Turn Key for abbreviations on the bottom of page 3.
7. Anti-embolic: Below the word “Anti-embolic” document type and location of product being used
e.g. “TED/SCD BLE”. In the small box
document “on” or
“off”.
In the small box document
whether the anti-embolic ordered is “on” or “off”.
8. Splints: Document next to the word “Splints” type and location of splints
e.g. AFO/BUE. Document in the small box
whether the splints ordered are “on” or “off”.
INVASIVE
LINES, INCISIONS/WOUNDS, DRESSING AND DRAINS (page 7)
Document
in this section is an assessment of these areas and any treatment performed. In
the
large box document the assigned number of area /
areas assessed, initial and time performed. In the
small box a
( √ ) indicates standard met, ( * )
indicates a deviation from the standard, (
∆ )
indicates site care or dressing change was performed.
1. Invasive lines: Document on the numbered lines the site
and type of invasive lines in use.
2. Incisions/Wounds: Document on the numbered lines the site
and type of incision or wound.
3. Dressings: Document on the numbered lines the type of
dressing that corresponds to the Incisions/Wounds on same numbered line.
KEYNOTE: When a
dressing change is done on a wound or incision a corresponding ( * ) entry must be made on the
correlating wound or incision small box and a focus note entry of dressing
change and assessment of wound / incision.
4. Drains: Document on the numbered lines the type of
drains in use and enter a ( * ) in
the small box due to the fact that all drains require an entry in the “Focus Note” to described color,
consistency, and type of drainage with each initial assessment.
VITAL
SIGNS (pages 8-11)
Document
vital signs in appropriate box under appropriate time. Each box represents 15
minute intervals.
Pages 8-9 cover 0700-1859 and 10-11 cover 1900-0659. Use ( * ) to
indicate need for focus note entry.
Blood
Pressure: Document
in front of the word “Blood Pressure”
the mechanism used, e.g.
In
the box
document the B/P under appropriate time.
Arterial Mean: Document mean arterial pressure in the box
under appropriate time.
Heart
Rate: Document
the heart rate in the box under the appropriate time.
Respirations: Document spontaneous respirations in the box
under the appropriate time.
Vent
Rate: Document
the set ventilator rate in the box under the appropriate time.
Temperature: In front of the word “Temperature” document route of measurement. In the box
document the temperature under the appropriate time.
Glucose/Initials: Document each glucose as performed, initial, and sign the front of the flow sheet.
Insulin/Units: Document insulin type and unit (the number only).
KEYNOTE: If patient is on an insulin drip, document to refer to the IV fluid section below. Insulin must be checked by two licensed personnel and documented in Sunrise.
Pacer
Mode/MA: Document pacemaker mode in half of the box
and document milliamps in the other half of box
under the appropriate time.
Cap/Rate: Document a ( √ ) in half of the box if
pacemaker has good capture. If not
document
( * ) a make focus note entry
regarding failure and action taken. Document the set rate of the
pacemaker in other half of the box
under the appropriate time.
Wires: In front of the “Wires” document locations:
A = atrial, V = ventricular, G = ground. In the box
under the appropriate time document a ( √ ) if wires meet standard, see
“ICU Documentation Standards”.
( * ) denotes deviation from
standard and would require a focus
note entry.
Hemodynamics
PAP: Pulmonary Artery Pressure, Systolic /
Diastolic
PCWP
/ CVP: Pulmonary
Capillary Wedge Pressure upper half of box and Central Venous Pressure
lower half of box.
CO / CI: Cardiac Output upper half of box and Cardiac
Index lower half of box.
SVR
/ SVRI: Systemic
Vascular Resistance upper half of the box and Systemic Vascular Resistance
Index
in the lower half of the box under the
appropriate time.
Pulse
Ox / SVO2: Pulse Oximetry in the first half of box and Saturated Venous
Oxygen in the lower half
of the box under the appropriate time.
Neuro
ICP
/ CPP: Document
Intracranial Pressure in the first box and Cerebral Perfusion Pressure in the
second box.
Pupil
Size: Document
pupil size R = right, L = left , under the appropriate
time. Use the “Pupils”
charting key to determine size.
Pupil
Response: Document
pupil response under the appropriate time.
Use the “Pupils” charting
key to determine response.
In the box under the appropriate time. Refer to the “
to obtain a total Glasgow Coma Scale score.
INTAKE
Document
all intake in this section. Note:
The first four lines are blank to document parental
fluids.
Volume/Dose: Use this area to document drips. In front of “Dose” document
how it’s administered, e.g.
“mcg/kg/min”,
then in the box document the number of mcg, units, etc. infusing and in front
of “Volume”
document the drug and concentration, e.g. “Dopamine
800 mcg/250” , then in the box document the cc’s
per hour.
Blood (page 8, 10)
All
blood products are documented in this section.
If you are giving multiple blood products, they
Can
be documented consecutively regardless of time given.
Component: Document type of blood product given e.g.
“PRBC” – packed red blood cells.
Amount: Document total volume given
GI (page 8, 10)
All gastrointestinal intakes are documented
in this area.
FT: FT = Feeding Tube, NGT = Nasogastric
Tube. Circle which one is ordered. In front of FT / NGT
Write the type of FT,
e.g. “DHT, GT, or JT” followed by type of tube feeding ordered.
Flushes: In
front of “Flushes” write time ordered.
In box enter amount ordered.
NGT/PO: Circle appropriate route. Place amount of volume given or taken in box
under appropriate time.
OUTPUT (page 8, 10)
Document any out put in this area.
Urine: In front of “Urine” document device used
e.g., “Foley, BSC” etc. In first half of
box document the
hour’s
total in cc’s and in the second half document the cumulative total.
Stool/Heme: In front of Stool / Heme
document device used e.g., “BSC, BMS” etc. When the patient has a bowl
movement, document the amount, consistency and color in the box under the
appropriate time. Also document a ( + ) or ( - ) for occult blood as ordered.
Blank lines in output
area can be used to document any additional drains.
Shift Totals (page 9, 11)
All IV fluid and feeding pumps should be cleared and totals
documented to right of the “1700 or 0500” column, along with all other intake
and output amounts.
24 Hour Total Intake and Output (top of page 11)
Document total Intake and Output for applicable shift. Shift leaving at 0700 will document totals
for the 24 hour period.
RESTRAINT ASSESSMENT (page 12)
Document per UAMS nursing
guideline E.
Pulmonary Treatment (page 14)
All pulmonary care given by nursing staff
will be documented in this area.
Time: Document time treatment performed.
Suctioned
/ CDB: Document
which treatment performed.
Amount: Document amount of secretions obtained.
Consistency: Document consistency of secretions.
Color: Document color of secretions.
Initials: Document initials.
Respiratory Key (page 14)
List of abbreviations for
respiratory documentation.
ECG RECORD (page 14)
Interpretation of strip will be documented
on appropriate lines and NOT on the rhythm strip.
TRANSFER/DISCHARGE
ASSESSMENT
(page 15)
To be completed on all transfers and or
discharges from units.
Transfer
time: Time
transfer occurred.
Armband
Checked: Note
presences of armband.
Respiratory Status: Note respiratory status at time of transfer.
Current Oxygen Status: Note oxygen route, concentration ordered and
current oxygen
saturation.
EKG
Rhythm: Note EKG
rhythm at time of transfer.
Discharge
VS: Document current
vital signs.
Dressings: Note location and integrity of all dressings
at time of transfer.
Skin
Integrity: Note skin
condition at time of transfer.
Pain Assessment: Note pain score at time of transfer.
Present IV: Note all IV’s
infusing at time of transfer.
Site: <