Intensive Care Unit

Nurse Rounding Chart

Name: ............................................. Age/Sex: ............... DOA: ..................... ICU Length of Stay: ..............
Medical Diagnosis: ....................................................................... Date:.......................

Neurological System: Cardiovascular System: Respiratory System: Gastrointestinal Genitourinary System:

Pulse Rate : Creatinine: ...........
Pain score: .................... Oxygen: System:
Max................./min
RASS: ................. Urea: ....................
O2............................L/min
GCS: E......+V......+M......=...../15 Min................./min Total NGF..................ml K+: .......................
Humidification: ...................
Pupil size : Rt.......... Na+:.....................
: Lt.......... BP: Ventilator settings: Total NG Asp.............ml
Pupil reaction: Rt........ Max............mm.Hg Vt:.............................ml
Pplat:.......................cm.H2O Dialysis: Yes No
: Lt......... Total drainage............ml
Min.............mm.Hg FiO2: ...................
UF removed..........ml
PEEP.......................cm.H2O
Infectious Disease Last stool passed…........
Medicines Ventilator Bundle:
Antibiotics: Temp. Max...............◦C Integumentary /
HOB (30-45°): ............... Total IVF...............ml
……………………..…….. Current Temp...........◦C 9 GI prophylaxis: .............. Musculoskeletal System
…………………………… WBC……………10 /L DVT prophylaxis: .......... Pressure Ulcer: Total UOP..............ml
Sedatives: Endocrine System: Yes No
Yes No SBT: .............................. Infection Control:
RBS: ..................... Stage: ..........................
………………………........ Insulin: .................. Foley date: .................
Last dose given:……......... ETT/Tracheostomy: Norton Score: ..............
Dose: ..................... Size: ............................ CVC date: ..................
Sedation Vacation:
Yes No Hematological System ET length at lips..................cm Physiotherapy: Dialysis Line date..........
------------------------- Hb: ......................... Cuff pressure................cm.H2O Yes No IV insertion date:........
Inotropes: Hct:........................ Intubated/Trach. on:
Yes No ................................ Family Update on: HAI : Yes No
Platelets:.................
………………………….. ………………………… ....................................
MORNING SHIFT EVENING SHIFT NIGHT SHIFT
Event: Yes………………………………… No Event: Yes………………………… No Event: Yes…………….. No

NURSING FORM