ICU GUIDE to Charting by SYSTEM FRANCE ELLYSON CAROL 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time; LOC: awake, alert, confused, agitated, lethargic, unresponsive; Behavior/Mood: pleasant, cooperative, anxious, withdrawn, sad, combative, Speech: verbal, non-verbal, slurred, language barrier, aphasic, receptive, expressive, pupils size, shape, reaction to light, Vision: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 dressing Dressings: 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