Question	Answer
Form Name	Icu Flowsheet
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	nicu cheat sheet, nicu flowsheet, neonatal report sheet, dortoms

Time	Site	Gluc	HCT	TESTS AND RESULTS
Time	Site	Meter	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

T	Behavior	Attempt	Behavior	Response			Type
I	Before	PO	During	to	Duration	Supports	of
M	Before	PO	During	to	Duration	Supports	of
M			Feeding
E	Feeding	Y/N	Feeding	Feeding			Nipple
E	Feeding	Y/N		Feeding			Nipple
			BOTTLE BREAST

Time	Site	pH	pCO2	pO2	BE

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