Patient Label

Intensive Care Flow Chart

Date………………………………Today’s Wt………………
 DM type I DM typeII HTN
Dx ………………………………………………………….
 IHD CVA Isolation
Adm Wt…………….. Adm Date …………….. ICUDay ……………..
 HCV HBV

VITAL SIGNS Hemodynamics Glucose

Invasive BP CVP B/S Acet- Insulin
Pulse Pain
Time Temp HR Resp NIBP Intervention one/
Oxy Score
BHBA
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

Page 1 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

1 6
2 7
3 8
4 9
5

INTAKE
Cardiac Infusions IV Fluids Blood Products NUTRITION TOTAL INTAKE
P
PRBC F
5 6 7 8 9 Hourly Running Hourly Running
1 2 3 4 Whole L Total TPN PO
/HR /HR /HR /HR /HR Total Total Total Total
Blood F
T
P
S
A
B
C
D
E

F
G

H
I
J
K
L
M
N
O
P
Q

R
S
T

U
V
W
X
Y
Z

Page 2 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

OUTPUT
VENTILATION DATA
NG URINE Drains
Hourly Running Tidal
/HR /HR Total /HR /HR /HR Total Rate
Total Total Fio2 Volume
Mode Mand Peep Ps
Mand
Spon Spon

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

Total Intake: 24 Hour Balance:

Total Output: Cumulative Balance:

Page 3 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

Eyes Verbal Motor
5 Normal ROM/ Muscles strength Spontaneous 4 Oriented 5 Obeys commands 6
4 Normal ROM /Can be overcome with To speech 3 Confused 4 Localize pain 5
resistance To pain 2 Inappropriate speech 3 Flexion withdrawal 4
3 Normal ROM /Against gravity only No eye opening 1 Vocalizes 2 Abnormal flexion 3
2 To overcome gravity visible or palpable No Vocalization 1 Abnormalextension 2
muscles Areflexic 1
1 Contractions No movement

1 2 3 4 5 6 7 8
PUPIL SCALE

Blood Gases Neurological Signature/

Pupils Limb Movement ID number
Blood Gases GCS

Eyes Best Best Total

Open Verbal Moto Rt Lt Rt Lt
Time pH PCO2 PO2 O2 Sat HCO3 BE Rt Lt Arm Arm Leg Leg
/4 /5 r
/15
/6
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

Page 4 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

Physical Assessment

Legend: √= Agree N/A= Not applicable

D N D N

Injury Free Abdomen Soft Firm

GASTROINTESTINAL
Pain Free Tender tender Distend

Pain/discomfort R/t Bowel Sounds Last Bm

No n ed
Anxiety / Free-mild Anxiety Continent udy ……
GENERAL

Calm cooperative
No Nausea Or Vomiting
Anxiety High
Diet:
Angry Demanding Combative
NPO
Agitated Depressed

GENITOURINARY
Patient/Family Coping with illness
Urine:Clear Clo Color:…… ……….
Patient /Family Coping with treatment
Continent No Freq Urgency Dysuria

Indwelling Urinary Catheter

Capillary Refill < 3 Sec Date: ……………….. Size: ………………… Type: …………………….

No Peripheral / Dependent Edema Jaundice Pale Cyanotic

Generalized Edema
CARDIOVASCULAR

Lower Extremities Edema Oral Mucosa – Pink, No Lesions

Pulses present or absent Turgor
RT LT No Impairment Of Skin
Radial Skin Lesions Rash Petechiae
Brachial Ecchymosis Other
Dorsalis pedis Pressure Ulcers Circle and Number
Posterior Tibial

VASCULAR ACCESS / TUBES

SITE INSERT SIZE

DATE SITE COND.
TYPE

INTEGUMENTARY
Number

Color

Length

Width

Drainage

O2 Treatment Stage

ETT/ Tracheostomy: Size Level at the lips Stages:

Breath Sounds …………............ 1. Red area non Bleachable

Cough 2. Blisters, skin break or tears

None Non Productive Productive 3. Exposed subcutaneous tissue

Secretions: 4. Exposed muscle or bone

Large Moderate Small 5. Unstageble

Consistency: Today’s Braden Score: …………………….

Thin Thick Frothy Nurse's Signature

Bloody Yellow Green Shift Nurse's Name ID number Initials

White Brown / Tan

Page 5 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

Routine checks
09 11 13 15 17 19 21 23 01 03 05 07

Bath Self  Assist  Dependent 

Mouth Care Self  Assist  Dependent 
Voiding Self  Assist  Dependent 
Turn And Position Self  Assist  Dependent 
Ambulatory Self  Assist  Dependent 
Range Of Motion Active  Passive 
Sleep/periods Of Rest
Feeding Self  Assist  Dependent 
NPO
Force / Restrict Fluids ml/day
Transducers: Zero / Calibrate
Alarm Parameters Set & On
Cough And Deep Breathing
Suction ETT/ Tracheostomy
Tracheostomy Care
Wound Care
1
2
3
Tube Care
1
2
3
Skin Care Protocol
Call Bell:  Glasses 
Hearing Aid  Dentures 
Arm Band:

Special instructions

Page 6 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

Nursing Clinical Notes
KEY Signature
TIME WORD NOTE /ID

Page 7 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:0

 Patient Label

Intensive Care Flow Chart

Nursing Clinical Notes
KEY Signature
TIME WORD NOTE /ID

Page 8 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019 Revision No.:

 Patient Lab

Page 9 of 9 NH-ICU-FRM-010 Issue No.:1 Revision Date: 09/12/2019

Revision No.:0