Icu Flowsheet – Fill Out and Use

Standards of Care

SHIFT

WEIGHT:

KG

LB

Time

Site

pH

pCO2

pO2

BE

Time

Site

Gluc

HCT

TESTS AND RESULTS

Meter

GRUNTING

UMBILICAL

POSITION/MISC

STOOL COLOR

ORAL(PO) FEEDING DESCRIPTION

A – Audible w/naked

CORD

P - Prone

M – Meconium

ear

O - Off

S – Supine

Y – Yellow

BEHAVIOR BEFORE FEEDING

S – Stethescope only

D - Dry

R - Rt. Side Down

G – Green

1

Infant awakens on own signaling

Int - Intermittent

W - Wet

L - Lt. Side Down

B – Brown

hunger with crying or fussing; shows

Cl - Clamped

HOB - Head of Bed Up

FB – FRANK BLOOD

hunger cues (rooting, sucking,

COLOR

DG - Drainage

HOB - Head of Bed

searching, hand to mouth).

P - Pink

R – Erythema

Down

CONSISTENCY

2 Infant awakens on own, may remain

W – Pale

confined to

IS – Infant Seat

S – Soft

quietly alert, drowsy or begin fussing or

D – Dusky

stump

SW – Swaddled

W - Watery

moving, may show some hunger cues

C – Cyanotic

Rt – Erythema

SG – Swing

P – Pasty

(rooting, sucking, searching, hand to

J – Jaundiced

extended to

H – Held

SD – Seedy

mouth).

PL – Plethoric

abdominal

Mu – Mucous

3

Infant awakens with care-giving and

M – Mottled

wall

OXYGEN MODE

begins to show hunger cues (rooting,

A -Acrocyannosis

I – Isolette

ENTERAL FEEDS

sucking, searching, show hand to

FONTANELLE

H – Hood

MODE

mouth, fussing).

PERFUSION

S – Soft, Flat

NC – Nasal Cannula

Po – Nipple

4

Infant awakens with care-giving,

N – CRT < 3 sec.

F – Full

MT – Mist tent

BF – Breastfeeding

appears quietly awake or somewhat

A – CRT > 3 sec.

T – Tense

TC – Trach Collar

CNG – Continuous

drowsy with limited hunger cues

B – Bulging

CPT

Nasogastric

(rooting, sucking, searching, hand to

SKIN TEMP

D – Depressed

P – Percussion

NG/OG – Gavage

mouth).

W – Warm

V – Vibration

5

Infant remains asleep or drowsy.

C – Cool

ACTIVITY

IV SITE CHECK

6

Infant appears to have limited

H – Hot

++ - Active, Alert

SUCTION SOURCE

W – Warm

physiological stamina required to

D - Diaphoretic

+ - Active to stim

O – Oral

C – Cool

sustain control and endurance for

L - Lethargic

N- Nares

E – Edematous

feeding attempt.

TURGOR

S - Sleeping

R – Erythematous

BEHAVIOR DURING BOTTLE FEEDING

G – Good

NC - Non-

SUCTION AMOUNT

N – Non-indurated,

1

Energetic with steady, coordinated

F – Fair

consolable

S – Small

Non-edematous,

suck-swallow throughout feeding; min

P – Poor

Q – Quiet

Mo – Moderate

Non-erythematous

to no  in resp. effort or color; easily

C - Crepitus

L – Large

Bl – Blanched

maintains tone, posture, remains calm

TONE

and completes feeding.

RASH SITE

N - Normal

TYPE

IV LOCATION

2

Initially energetic with steady,

PA – Perianal

 - Hypertonic

Th – Thin

RAc – Right Antecubital

coordinated suck-swallow; has some

PN – Perineal

 - Hypotonic

Tk – Thick

LAc – Left Antecubital

challenges (suck-swallow

G – Generalized

J - Jittery

C – Clear

RF – Right Foot

coordination,  in resp. effort, color,

T – Trunk

C – Clonus

W – White

LF – Left Foot

tone, posture or state) with support, is

Y – Yellow

RH – Right Hand

able to complete feeding.

EDEMA

CRY

G – Green

LH – Left Hand

3 Initially slow to start or passive; has

G – Generalized

L - Lusty,

BRB – Bright Red Blood

RW – Right Wrist

challenges (with suck-swallow

Ex – Hands and Feet

Vigorous

P – Plugs

LW – Left Wrist

coordination, resp. effort, color, tone,

PO – Periorbital

W - Weak

Br – Brown

RAk – Right Ankle

posture or state); needs support

Hi - High-pitched

LAk – Left Ankle

throughout and may or may not

ABDOMINAL

A - Appropriate

ASPIRATE TYPE

S – Scalp

complete feeding.

S – Soft

for age

M – Mucous

B – Broviac

4

Initially energetic or slow to start;

ND – Non-Distended

HO-Hoarse

F – Formula

PQ – Per-Q-Line

becomes disorganized; shows

Ts – Tense

Q - Quiet

B – Bilious

instability (in suck-swallow

Tn – Tender

FB – Frank Blood

BLOOD GAS SITE

coordination, resp. effort, color, tone,

DC – Discolored

PAIN SCREEN

CG – Coffee Ground

HS – Heel Stick

posture or state); is unable to complete

D – Distended

 pain screen

A – Air

VS – Venous Stick

feeding.

F – Full

performed-no

FS – Finger Stick

5

(*) Concerning feeding behaviors or

“triggers” for pain

DISPOSITION

Art – Arterial Stick

oral motor patterns; may appear

BOWEL SOUNDS

*Refer to pain

A – Aspirate

disinterested or upset with feeding

-

- Absent

assessment

D- Discarded

CIRC

attempts or may awaken but is unable

+

- Present, Active

scale

R- Ref

CL – Clean

to coordinate suck-swallow for feeding.

 - Decreased

DG – Drainage

 - Hyperactive

BL - Bleeding

TYPE OF NIPPLE

Y - Yellow

SF- Slow Flow

R - Red

P - Playtex

N - Nuk

H - Haeberman

G – Gerber Premie

SL=Slit

Eff. 9/1/11 Rev.

Page 3 of 4

ENTERAL INTAKE

PARENTERAL INTAKE

OUTPUT

Solution:

MODE

TOTAL

E

URINE

STOOL

T

F

M

AMT

I

O

ASP

E

Dext%

Total

IL

Total

Site

COLOR

M

R

S

CONSIS

AMT

E

M

I

Type

U

S

L

RATE

Hourly

Rate

A

Bolus

URINE

Hourly

W/STOOL

Rate

Hourly

Location