CRITICAL CARE

FLOW SHEET
PATIENT IDENTIFICATION
START DATE:

STOP DATE:

SIGNATURE / TITLE / INITIALS

SIGNATURE / TITLE / INITIALS

TYPE:
WT Today:

KG
WT Yesterday:

HT:

Arterial Line

Central Line

Central Line

Sheath

Other

Insertion
Date

LBS

PAST 24
Intake

PA Catheter

BALANCE 24

Insertion
Site

Output

Removal
Date

LAB DATA
LABWORK

RESULTS

LABWORK

TIME

Time

BS

Albumin

BUN

WBC

Cr

Hgb

Na

Hct

PT

Cl

INR

CO2

PTT

Ca

Platelets

Phos

CPK

Magnesium

CK - MB

Cholesterol

CPK Index

Total Bili

Troponin

Alk. Phos
SGOT

Lactic Acid
NH4

SGPT

Pre-Albumin

Total Protein

Digoxin

TIME

STAT MEDS

ISOLATION

YES
NO

PATHWAY
CODE STATUS

NO

8850122 Rev. 05/05

TIME

INITIALS

ISOLATION
TYPE:

NEGATIVE FLOW
MAINTAINED:

RESULTS

STAT MEDS

YES
NO

INITIALS

N/A
HEPAFILTER

YES; If "YES", SPECIFY:

FULL CODE

DNR

OTHER:

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

PAGE 1 of 6

Critical Care Vital Sign Flow Sheet

HOUR
07 - 07
MINUTE
:00 - :59
240

240

220

220

200

200

180

180

160

160

140

140

120

120

100
BP Method
A = A-Line
C = Cuff 80
D = Doppler

100

><

PULSE

BP

80

60

60

40

40

20

20

TEMP
Respirations
BP Method
MAP
CVP
PAS
PAD
PCWP
CO/CI
SVR
Pulse Ox
Accu-Check
Radial
P
R/L
U
L Dorsalis
Pedal
S
R/L
E
S
R/L

PULSES (Code):

O = Absent

D = Doppler

1+ = Intermittent

2+ = Weak

3+ = Strong

Hematoma
Sandbag

INVASIVE LINE CARE

CHECK WHEN CHANGED
P
E
R
I
P
H
E
R
A
L

#1 DATE
SITE
#2 DATE
SITE
#3 DATE
SITE

8850122 Rev. 05/05

CHECK WHEN CHANGED U P CHECK WHEN CHANGED U P CHECK WHEN CHANGED U P

C
E
N
T
R
A
L

CORDIS TUBING
PROX. TUBING
MEDIAL TUBING
DISTAL TUBING
DRESSING

S
W
A
N

DRESSING

G
A
N
Z

CO SET TUBING

PRESSURE TUBING
FLUSH BAG

A
L
I
N
E
O
T
H
E
R

DRESSING
PRESSURE TUBING
FLUSH BAG
TUBING

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

PAGE 2 of 6

DRUG DOSAGE (mcg/kg/min., mcg/min., etc.)

INTRAVENOUS
mcg
or
mg
mcg
or
mg
mcg
or
mg
mcg
or
mg
mcg
or
mg
mcg
or
mg

07

08

09

10

11

12

13

14

8 Hour
Total

DRIP WEIGHT:____________(KG)
15

16

17

18

19

20

21

22

8 Hour
Total

23

24

01

02

03

04

05

06

8 Hour
Total

24 Hour
Total

8 Hour
Total

24 Hour
Total

ml

ml

ml

ml

ml

ml

PPN
TPN
INTRALIPIDS

BLOOD
PRODUCTS
I.V. MEDS

CO INJECTATE
TUBE FEEDING
NG MEDS
PO FLUIDS /
FREE H2 O

TOTAL
INTAKE
07

08

09

10

11

12

13

14

8 Hour
Total

15

16

17

18

19

20

21

22

8 Hour
Total

23

24

01

02

03

04

05

06

URINE
HEMODIALYSIS
FLUID REMOVAL

NG
STOOL
DRAINS

IV SITE Q 2 Hrs
CHECKS
POSITION
R/L/B/C
R = Right Side
L = Left Side

DIET INTAKE
Breakfast
8850122 Rev. 05/05

TOTAL
OUTPUT

B = Back
C = Chair

ALL

> 1/2 < 1/2

DIET INTAKE
Lunch

ALL

> 1/2 < 1/2

DIET INTAKE
Dinner

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

ALL

> 1/2 < 1/2

PAGE 3 of 6

NEUROLOGICAL ASSESSMENT
TIME
INITIALS

PUPILS

B = Brisk
S = Sluggish
- = No
Reaction
C = Eye Closed

Size
Right
Reaction
Size
Left
Reaction
Please use numbers scale

C
O
M
A
S
C
A
L
E

Eyes
open

Best
verbal
response

Best
motor
response

Eyes closed
by swelling
=C

Spontaneously=4
To sound=3
To pain =2
None=1
Oriented=5
Confused=4
inappropriate
words=3
Incomprehensible
sounds=2
None=1
Obey commands=6
Localize pain=5
Withdraws=4
Flexion to pain=3
Exten. To pain=2
None=1

Endotracheal
tube or
tracheostomy
=T

Record best
limb response

GLASCOW COMA SCALE TOTAL

E
X
T
R
E
M
I
T
Y

L
E
F
T
R
I
G
H
T

Hand

Consciousness

Leg

Extremities

A = alert
L = lethargic
/ drowsy
R = restless
C = confused
CT = comatose
S = stuporous
/ obtunded

Hand
Leg

Consciousness
Seizure Activity

S = strong or
normal
W = weak
M = slight
movement
A = absent or
paralyzed

Speech

FALL PREVENTION STANDARD

N
D

PART ONE: RESTRAINT INTERVENTION

E

N/A

Fall Standard in Use

If initial order, document time restraints applied:

MILITARY TIME

1 Indication for use of restraints:

Yellow ID band on Patient

2 Alternative intervention(s) attempted prior to restraint applications

Yellow Card on Door

Nursing interventions - i.e., securing tubing, dressing

Diversional activity - i.e., music, puzzles, etc.
Spend more time with patients
Family / significant other involvement

Call Light in Reach

Bed Low & Locked

3 Alternative measures effective:

Bed Alarm On
Side Rails Up

X2

4 Education

X4

PART TWO: OBSERVATION SHEET

TIME

Interference with medical treatment

Risk of Falls

0800

1000

1200

1400

1600

2000

2200

2400

0200

0400

0600

Hydration /
Nutrition
Toilet /
Comfort
Skin
Checked

No

a. Patient / significant other educated on restraint

5 Type & location of restraint(s) in use:

6 a.

Restraint Standard for Acute Care Setting in use:

b. Acute Confusional State Standard in use:

Yes
Yes

No
No

Indicate Time(s) Patient OUT OF RESTRAINTS

ROM
Circulation
Checked
LOC / Mental
/ Emotional
Staff
Initials

N
D
E
ROUTINES & SAFETY

SHIFT

ROUTINES & SAFETY

U

Back Care
Bath
Oral Hygiene
Foley Catheter
Ted / SCD / Plexiplus
Lines Zeroed
Activity ( BR, BRP, Chair, Ambulatory )

8850122 Rev. 05/05

Yes

Yes
No
alternatives + reason(s) for restraint use:
Yes
No
b. Patient / significant other verbalized understanding
Not understood by patient; significant other unavailable

Directions: Document
every 2 hours (MST / CCT may complete)
1800

Environment change
Reduce stimuli
Reality orientation
Bed alarm

SHIFT
Bed Surface
M = Maxifloat

U
S = Softcare

O = Other / Specialty Bed ( Specify )

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

PAGE 4 of 6

TIME

P
A
C
E

RHYTHM
S1

S2

S3

Gallop
Murmur
Fx Rub

SKIN

+ / - = PRESENT / ABSENT

COLOR
JVD
EDEMA / LOCATION
CAPILLARY REFILL

B
R
E
A
T
H

MODE
TYPE
RATE / MA

F
N
P
C
J
D
M

=
=
=
=
=
=
=

FLUSHED
NORMAL / PINK
PALE
CYANOTIC
JAUNDICED
DUSKY
MOTTLED

+ / - = PRESENT / ABSENT

RML
RLL
LUL
LLL

N
G
P
NP
T
1+
2+
3+
4+

=
=
=
=
=
=
=
=
=

R
I
S
L
H

=
=
=
=
=

NONE
GENERALIZED
PITTING
NON-PITTING
TRACE
2 MM PITTING
4 MM PITTING
6 MM PITTING
8 MM PITTING

RESPIRATIONS

REGULAR
IRREGULAR
SHALLOW
LABORED
HYPERVENTILATION
( RATE & DEPTH)
0* = OTHER
(Asterisk & Describe)

SITE
DRAINAGE /

(Describe)
H2O SEAL /
Bubbling +/SUCTION /
(CmH2O)

BREATH SOUNDS
CL
RA
RH
WZ
E
I

ABDOMEN
BOWEL SOUNDS
G
STOOL: description
I
NG: description

=
=
=
=
=
=
=
O =
BR =

CLEAR
RALES / CRACKLES
RHONCHI
WHEEZE
EXPIRATORY
INSPIRATORY
DECREASED
ABSENT
BRONCHIAL

FL
D
L
T
S
F
R

FLAT
DISTENDED
LARGE
TENDER
SOFT
FIRM
RIGID

ABDOMEN

URINE: (color, char.)

G
Method of output
U

=
=
=
=
=
=
=

BOWEL SOUNDS
+ = PRESENT

COMMENTS:

8850122 Rev. 05/05

WARM
COOL
COLD
HOT
DIAPHORETIC
CLAMMY
MOIST
DRY

EDEMA

SECR. COLOR AMT.

T
U
B
E
S

=
=
=
=
=
=
=
=

JVD
RUL

S
O
U
N
D
S

W
CL
CD
H
DI
CLA
M
DR

COLOR
R/L

SUCTION

C
H
E
S
T

S4

SKIN

M
A
K
E
R

PRESENT
DECREASED
S
S
1
2 S

MURMUR/FRICTION RUB

RESPIRATIONS

R
E
S
P
I
R
A
T
O
R
Y

=
=

GALLOP
S

S
O
U
N
D
S

H
E
A
R
T

O2 SAT

CODES
HEART SOUNDS

INITIALS
C
A
R
D
I
O
V
A
S
C
U
L
A
R

HCO3

paO2

pH

TIME

paCO2

ABGS

HOB 30

CM Mark

R = Right
M = Middle
L = Left

Position

Size

PC / IE

Peak / Mean
Press Insp

PEEP / PS

Vent Rate /
Spont.

Vent Mode

TIME

Equipment

Oxygen %
FiO2 / LPM
Tidal
Volume
Spontaneous TV

RESPIRATORY
TRACH / ET TUBE

= HYPOACTIVE
= HYPERACTIVE
O = ABSENT

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

PAGE 5 of 6

PAIN MANAGEMENT
COMFORT GOAL:
TIME

RATING SCALE:
SEDATION
PAIN
RATING
RATING

PAIN LOCATION

INTERVENTION

EVALUATION
TIME/PAIN #

INITIALS

INITIALS

PAIN SCALES:
WONG-BAKER:

(Faces)

0-10 VISUAL:
(Numeric)
VERBAL:
NON-COGNITIVE:

No Hurt

( FLACC Scale )

Hurts Little Bit

Hurts Little More

Hurts Even More

FLACC PAIN SCALE:

S = NORMAL SLEEP, EASY TO AROUSE, ORIENTED WHEN AWAKENED, APPROPRIATE

COGNITIVE BEHAVIOR

1 = WIDE AWAKE - ALERT (OR AT BASELINE), ORIENTED, INITIATES CONVERSATION

2 = DROWSY, EASY TO AROUSE, BUT ORIENTED AND DEMONSTRATES APPROPRIATE
COGNITIVE BEHAVIOR WHEN AWAKE

3 = DROWSY, SOMEWHAT DIFFICULT TO AROUSE, BUT ORIENTED WHEN AWAKE

4 = DIFFICULT TO AROUSE, CONFUSED, NOT ORIENTED
5 = UNAROUSABLE

INTERVENTION:
1 = DISCUSS PAIN MANAGEMENT PLAN WITH PHYSICIAN
2 = PHARMACOLOGICAL (See MED KARDEX)
A. Position Changed
3 = NON-PHARMACOLOGICAL

B. Relaxation Technique
C. Splinting
D. Imagery
E. Music
F. Education
G. Other: ___________________________________________________

1. TOTALLY LIMITED
2. VERY LIMITED
3. SLIGHTLY LIMITED
4. NO IMPAIRMENT

Hurts Whole Lot

10
Worst Pain

WONG-BAKER FACES PAIN SCALE from Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Ahmann E, DiVito-Thomas PA, Whaley & Wong:
Care of Infants & Children, 6th ed, St. Louis, MO: Mosby-Year Book Inc., 1999; 1153. Copyrighted by Mosby-Year Book, Inc. Reprinted with Permission.

SEDATION SCALE:

SENSORY PERCEPTION

1. Sum of FACE, LEGS, ACTIVITY, CRY &

CONSOLABILITY Scores = FLACC Score
2. Record FLACC Score using the 0-10
VISUAL (NUMERIC) Scale above

_____ = FACE Score

0 = No particular expression or smile
1 = Occasional grimace or frown, withdrawn, disinterested
2 = Frequent to constant frown, clenched jaw, quivering chin
_____ = LEGS Score
0 = Normal position, or relaxed
1 = Uneasy, restless, tense
2 = Kicking, or legs drawn up
_____ = ACTIVITY Score
0 = Lying quietly, normal position, moves easily
1 = Squirming, shifting back & forth, tense
2 = Arched, rigid, or jerking
_____ = CRY Score
0 = No crying (asleep or awake)
1 = Moans or whimpers, occasional complaint
2 = Crying steadily, screams or sobs, frequent complaints
_____ = CONSOLABILITY Score
0 = Content, relaxed
1 = Reassured by touching, hugging, talking to, distractable
2 = Difficult to console or comfort

PRESSURE SORE RISK ASSESSMENT:

MOISTURE

1. TOTALLY MOIST
2. VERY MOIST
3. OCCASIONALLY MOIST
4. RARELY MOIST

ACTIVITY

1. BEDREST
2. CHAIRFAST
3. WALKS OCCASIONALLY
4. WALKS FREQUENTLY

TO BE COMPLETED EVERY 24 HRS

MOBILITY
NUTRITION
FRICTION & SHEAR

1. TOTALLY IMMOBILE
2. VERY LIMITED
3. SLIGHTLY LIMITED
4. NO LIMITATIONS

1. VERY POOR
2. PROBABLY INADEQUATE
3. ADEQUATE
4. EXCELLENT

1. PROBLEM
2. POTENTIAL PROBLEM
3. NO APPARENT PROBLEM

SCORE:
IF TOTAL SCORE < 17, PATIENT IS AT HIGH RISK FOR PRESSURE ULCER
IMPLEMENT PRESSURE ULCER PREVENTION PROTOCOL IMMEDIATELY

WOUND CARE:

TOTAL SCORE:
COMPLETED BY:

SERUM
ALBUMIN

On ADMISSION + every THURSDAY

STAGE:
I=
II =
III =
IV =

Reddened area (intact skin)

Blister, skin break
Skin break exposing subcutaneous tissue
Skin break exposing muscle and / or bone

PERI-WOUND TISSUE:

WNL =
R=
D=
M=

Within Normal Limits

Reddened
Darkened
Macerated

P = Pink / Clean
S = Slough
E = Eschar
O = None
M = Mild
F = Foul
APPEARANCE:
ODOR:
O = None
S = Serous
SG = Sero-sanguinous
P = Purulent
DRAINAGE:
NA
ADDITIONAL DRESSING CHANGES DOCUMENT IN PROGRESS NOTES
If more than 5 wounds, use OVERLAY

(Legend)

TYPE
Venous
Stasis
Pressure
Ulcer
Traumatic
Wound

SHIFT:
U
LOCATION: WOUND #:
TYPE (Legend): TYPE:
Stage:
Appearance:
Drainage:
Odor:
Peri-Wound Tissue:
Size [L x W x D]#
cm:
Undermining [Y / N]:
Nurse's Initials:
Irrigation:
Treatment:
Time / Initials:

8850122 Rev. 02/05

U
WOUND #:
TYPE:

U
WOUND #:
TYPE:

U
WOUND #:
TYPE:

PART OF THE MEDICAL RECORD

Critical Care Flow Sheet_NURSING_CRITICAL CARE

U
WOUND #:
TYPE:

PAGE 6 of 6