NCM 118B-ZCMC-MICU Name of Students: ________________________

Rotation/Date/Day: ________________________________
HRN: ______________ Date of Admission: ______________________ Bed #: ____________
Diagnoses:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Time: _________
General Appearance:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Contraptions:
Type of Solution/Volume Fluid Level IVF IV site Date/time
Drug incorporated/Titration/Rate Intake started;
1st Last Date/time to
Checked Checked consume
1.

2.

3.

4.

Cardiac Monitor: _______________________________________________________________

O2 Therapy: ___________________________________________________________________
MV Settings: Mode: _______________ TV: _________________
PEEP: _______________ FiO2: _______________
BUR: _______________ PS: __________________
I: ____________________
E: ____________________

RUC: ________________________________________________________________________

Daily Nursing Care- MICU page 1 of 5

NGT: ________________________________________________________________________
Restraints: ____________________________________________________________________
Drains: _______________________________________________________________________
Others: _______________________________________________________________________

Received Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Vital Signs
Time BP HR/PR O2 sat Temp RR Pain MAP

GCS
Time Eye Opening (4) Verbal (5) Motor (6) Total (15)

NGT Feeding
Time Feeding Rx Tube Length Residuals Volume of Flushing
Type/Amount/Freq Placement Feeding (water)

Intake and Output

Time Intake Output
IVF/Medications Oral/NGT Urine/Drains BM

Total
CBG/SRI
Time CBG SRI

Daily Nursing Care- MICU page 2 of 5

 Medications
Time Medication Parameter Dose Route Frequency

Nursing Care
Nursing Diagnosis (F) Nursing Actions (A) Evaluation (R)
Cues (S/O) (D)
#1.

#2.

Daily Nursing Care- MICU page 3 of 5

#3.

#4.

Nurse’s Notes
Date/ Focus Data/Action/Response Signature/
Time Printed Name

Daily Nursing Care- MICU page 4 of 5

Daily Nursing Care- MICU page 5 of 5