Printable Nicu Report Sheet Details

The Icu Flowsheet Form is a tool that allows critical care nurses to track the progress of their patients. Using the form, nurses can record information about vital signs, treatments, and other important data. This allows nurses to provide rapid and accurate care to their patients. The form is also helpful in tracking patient progress and ensuring that all treatment goals are met.

You can definitely find it beneficial to understand the amount of time you'll need to prepare this icu flowsheet and exactly how lengthy this form is.

QuestionAnswer
Form NameIcu Flowsheet
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnicu cheat sheet, nicu flowsheet, neonatal report sheet, dortoms

Form Preview Example

Connecticut Children’s NICU

at UConn Health Center

282 Washington Street

Hartford, CT 06106

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Patient Identification)

 

 

 

 

 

 

 

 

 

Newborn/Intermediate Flowsheet – Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RN SIGNATURE

 

 

INITIALS

 

RN SIGNATURE

 

 

 

 

INITIALS

 

 

 

RN SIGNATURE

 

 

 

INITIALS

RN SIGNATURE

 

INITIALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VITAL SIGNS

 

 

 

 

 

 

 

 

 

ASSESSMENTS

 

 

 

 

 

PAIN

 

 

RESPIRATORY SUPPORT

 

SUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Screen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

ISC

INFANT

HR

RR

BP

BP

BREATH

EQUAL

GRUNT

COLOR

SKIN

RASH

ABD

UMB

FONT

TONE

CIRC

 

 

 

 

 

 

 

 

 

 

 

SOURCE

 

 

 

 

 

 

 

 

 

MEAN

SOUNDS

 

 

 

 

 

TEMP

SITE

 

 

 

 

 

 

TIME

MODE

FiO2

FLOW

 

SPO2

Oximeter

NEB

 

 

TYPE

INIT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TREND

SITE

RX

 

 

 

 

 

 

SKIN

 

 

 

RESP

 

 

 

AIR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

’D

 

 

 

 

 

 

 

TEMP

BED

QUAL

PATTERN

S/D

SITE

ENTRY

RETR

FLARIN

PERF

TURGOR

EDEMA

BS

GIRTH

ACTIV

CRY

POSIT

*

 

 

 

 

 

 

 

 

 

CPT

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eff. 9/1/11 Rev.

Page 1 of 4

Connecticut Children’s NICU

at UConn Health Center

282 Washington Street

Hartford, CT 06106

(Patient Identification)

Newborn/Intermediate Flowsheet – Date:

Standards of Care

SHIFT

Care of the Infant with:

Admission to the Newborn Nursery

Apnea/ Bradycardia /Periodic Breathing

Breastfeeding/Breast Pumping

Bronchodilators

Cardiorespiratory Monitor

Central Lines

Circumcision

Developmental Assessment and Care

Discharge Planning: Neonatal

Feeding: NG/OG/Continuous/Intermittent

GE Reflux

Grieving

Hospitalized Infant: Care of the Family

IV Therapy

Kangaroo Care

Pain Screening and Assessment

Phototherapy/Biliblanket

Pulse Oximetry

Skin Care: Neonatal

Steroids

Supplemental Oxygen

Thermoregulation

Well Newborn

Other:

PATIENT AND FAMILY TEACHING RECORDS:

Family Education of the hospitalized Infant

BPD

Others:

SHIFT

SAFETY:

ALARMS:

HR: HIGH / LOW

RR: HIGH/Apnea > 20 sec.

Pulse Oximetry: Low

Security Sensor On:

EQUIPMENT:

Resuscicard

Bag/Mask & O2 Flow

Suction Set-up

ID & Blood Bracelet

Evacuation Pack & ID

PHOTOTHERAPY:

Photo Tx Intensity

Eye Patches

Serum Bili Level

HYGIENE:

Bath/Linens

Cord Care

Circ. Care

Nares Care

Mouth Care

PARENT COMMUNICATION:

WEIGHT:

KG

LB

Birth Weight:

Yesterday:

Today:

Wt change:

Length:OFC:

Corrected Gestational Age:

Mom’s Room #

Care Level:

Physician:

BLOOD GAS RESULTS

Time

Site

pH

pCO2

pO2

BE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAB TESTS/RESULTS

Time

Site

Gluc

HCT

TESTS AND RESULTS

Meter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOOL/URINE RESULTS

COMMENTS:

Eff. 9/1/11 Rev.

Page 2 of 4

Connecticut Children’s NICU

at UConn Health Center

282 Washington Street

Hartford, CT 06106

(Patient Identification)

Newborn/Intermediate Flowsheet – Date:

GENERAL

R – Right

L – Left

- Done

-- Absent

+ - Present - Increased - Decreased

- Asymmetrical = - Equal

- Changed

BED

I – Isolette

OC – Open Crib

OW – Open Warmer

HR QUALITY

R – Regular

I – Irregular

M – Murmur

RESP. PATTERN

R – Regular

IR – Irregular

S – Shallow

PB – Periodic

Breathing

BP SITE

LA – Left Arm RA – Right Arm

LL– Left Calf RL – Right Calf LT – Left Thigh RT – Right Thigh

BREATH SOUNDS

Cr – Crackles

C – Clear

CO – Coarse

W – Wheeze

S – Stridor

AIR ENTRY

G – Good

L – Limited

T – Tight

EQUALITY

++- Bilaterally RorL- Diminished  - Diminished

bilaterally

RETRACTIONS

M – Minimal

MO – Moderate

S – Severe

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

 

 

BEHAVIOR DURING BREASTFEEDING

1Latches on without difficulty with strong, steady and rhythmic sucks; briefly pauses and readily resumes sucking; frequent,

coordinated suck- swallowing heard

2Latches on without difficulty with strong, steady and rhythmic sucks; briefly pauses

and resumes sucking without help; some swallowing heard.

3 Latches on with minimum difficulty; sucks are short and quick without steady rhythm; pauses and needs help to resume sucking; occasional swallowing heard.

4Roots or licks; latches on with difficulty; briefly maintains latchon or does not suck;

no swallowing heard.

5 Roots or licks; unable to latch on for breastfeeding attempt.

6No effort (sleepy, lacks energy, has no interest, cries, squirms, or pushes away) despite much assistance, unable to successfully attempt breastfeeding.

RESPONSE TO FEEDING

1Appears satiated and comfortable; becomes relaxed, quietly interactive or sleepy without

physiologic changes.

2Becomes tired and fatigued from feeding; has minimal in HR, resp, color or tone.

3Exhausted or taxed by feeding; has changes in resp, color, loss of tone or other

physiologic signs (hiccups, grunts/sounds, cough/choke, head bobbing, O2 sats)

resulting from efforts to feed.

4Has difficulty settling; appears uncomfortable following feeding (shifting within position, straining, spitting, fussiness and/or increased respiratory effort).

SUPPORTS

OB - Occasional Breaks/Pauses

FB - Frequent Breaks/Pauses

PH - Pacing Help

BU - Frequent Burps

FA -Flow Adjustment

SP - Sidelying Position

OP - Other Position

CS - Chin/Cheek Support

OX - Oxygen

EN - Environment

Other - Specify

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

Connecticut Children’s NICU

at UConn Health Center

282 Washington Street

Hartford, CT 06106

(Patient Identification)

Newborn/Intermediate Flowsheet – Date:

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

FORMULA

SCF-SPECIAL CARE S-SIMILAC SFe-SIMILAC WITH Fe Alim-ALIMENTUM BM-BREAST MILK NS-NEOSURE ISO-ISOMIL PREG-PREGESTIMIL ENF-ENFAMIL

SUPPLEMENTS NC-NATURAL CARE NSP- NEOSURE POWDER NCTP-NEOCATE POWDER HMF-HUMAN MILK FORTIFIER RC-RICE CEREAL

FORMULA TYPE/CALORIE

#1__________________________

#2__________________________

#3__________________________

ORAL (PO) FEEDING DESCRIPTION * See Codes

T

Behavior

Attempt

Behavior

Response

 

 

Type

I

Before

PO

During

to

Duration

Supports

of

M

 

 

Feeding

 

 

 

 

E

Feeding

Y/N

Feeding

 

 

Nipple

 

 

 

 

 

 

 

BOTTLE BREAST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS:_______________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Eff. 9/1/11 Rev.

Page 4 of 4

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