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

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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