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.
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 |
Connecticut Children’s NICU
at UConn Health Center
282 Washington Street
Hartford, CT 06106
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(Patient Identification) |
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Newborn/Intermediate Flowsheet – Date: |
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RN SIGNATURE |
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INITIALS |
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RN SIGNATURE |
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INITIALS |
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RN SIGNATURE |
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INITIALS |
RN SIGNATURE |
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INITIALS |
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VITAL SIGNS |
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ASSESSMENTS |
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PAIN |
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RESPIRATORY SUPPORT |
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SUCTION |
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Screen |
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Time |
ISC |
INFANT |
HR |
RR |
BP |
BP |
BREATH |
EQUAL |
GRUNT |
COLOR |
SKIN |
RASH |
ABD |
UMB |
FONT |
TONE |
CIRC |
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SOURCE |
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MEAN |
SOUNDS |
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TEMP |
SITE |
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TIME |
MODE |
FiO2 |
FLOW |
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SPO2 |
Oximeter |
NEB |
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TYPE |
INIT |
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TREND |
SITE |
RX |
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SKIN |
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RESP |
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AIR |
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’D |
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TEMP |
BED |
QUAL |
PATTERN |
S/D |
SITE |
ENTRY |
RETR |
FLARIN |
PERF |
TURGOR |
EDEMA |
BS |
GIRTH |
ACTIV |
CRY |
POSIT |
* |
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CPT |
AMOUNT |
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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
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 |
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LAB TESTS/RESULTS
Time |
Site |
Gluc |
HCT |
TESTS AND RESULTS |
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Meter |
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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 |
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A – Audible w/naked |
CORD |
P - Prone |
M – Meconium |
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ear |
O - Off |
S – Supine |
Y – Yellow |
BEHAVIOR BEFORE FEEDING |
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S – Stethescope only |
D - Dry |
R - Rt. Side Down |
G – Green |
1 |
Infant awakens on own signaling |
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Int - Intermittent |
W - Wet |
L - Lt. Side Down |
B – Brown |
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hunger with crying or fussing; shows |
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Cl - Clamped |
HOB - Head of Bed Up |
FB – FRANK BLOOD |
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hunger cues (rooting, sucking, |
COLOR |
DG - Drainage |
HOB - Head of Bed |
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searching, hand to mouth). |
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P - Pink |
R – Erythema |
Down |
CONSISTENCY |
2 Infant awakens on own, may remain |
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W – Pale |
confined to |
IS – Infant Seat |
S – Soft |
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quietly alert, drowsy or begin fussing or |
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D – Dusky |
stump |
SW – Swaddled |
W - Watery |
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moving, may show some hunger cues |
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C – Cyanotic |
Rt – Erythema |
SG – Swing |
P – Pasty |
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(rooting, sucking, searching, hand to |
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J – Jaundiced |
extended to |
H – Held |
SD – Seedy |
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mouth). |
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PL – Plethoric |
abdominal |
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Mu – Mucous |
3 |
Infant awakens with |
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M – Mottled |
wall |
OXYGEN MODE |
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begins to show hunger cues (rooting, |
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A |
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I – Isolette |
ENTERAL FEEDS |
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sucking, searching, show hand to |
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FONTANELLE |
H – Hood |
MODE |
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mouth, fussing). |
PERFUSION |
S – Soft, Flat |
NC – Nasal Cannula |
Po – Nipple |
4 |
Infant awakens with |
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N – CRT < 3 sec. |
F – Full |
MT – Mist tent |
BF – Breastfeeding |
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appears quietly awake or somewhat |
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A – CRT > 3 sec. |
T – Tense |
TC – Trach Collar |
CNG – Continuous |
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drowsy with limited hunger cues |
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B – Bulging |
CPT |
Nasogastric |
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(rooting, sucking, searching, hand to |
SKIN TEMP |
D – Depressed |
P – Percussion |
NG/OG – Gavage |
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mouth). |
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W – Warm |
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V – Vibration |
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5 |
Infant remains asleep or drowsy. |
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C – Cool |
ACTIVITY |
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IV SITE CHECK |
6 |
Infant appears to have limited |
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H – Hot |
++ - Active, Alert |
SUCTION SOURCE |
W – Warm |
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physiological stamina required to |
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D - Diaphoretic |
+ - Active to stim |
O – Oral |
C – Cool |
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sustain control and endurance for |
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L - Lethargic |
N- Nares |
E – Edematous |
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feeding attempt. |
TURGOR |
S - Sleeping |
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R – Erythematous |
BEHAVIOR DURING BOTTLE FEEDING |
||
G – Good |
NC - Non- |
SUCTION AMOUNT |
N – |
1 |
Energetic with steady, coordinated |
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F – Fair |
consolable |
S – Small |
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P – Poor |
Q – Quiet |
Mo – Moderate |
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to no in resp. effort or color; easily |
||
C - Crepitus |
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L – Large |
Bl – Blanched |
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maintains tone, posture, remains calm |
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TONE |
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and completes feeding. |
RASH SITE |
N - Normal |
TYPE |
IV LOCATION |
2 |
Initially energetic with steady, |
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PA – Perianal |
- Hypertonic |
Th – Thin |
RAc – Right Antecubital |
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coordinated |
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PN – Perineal |
- Hypotonic |
Tk – Thick |
LAc – Left Antecubital |
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challenges |
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G – Generalized |
J - Jittery |
C – Clear |
RF – Right Foot |
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coordination, in resp. effort, color, |
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T – Trunk |
C – Clonus |
W – White |
LF – Left Foot |
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tone, posture or state) with support, is |
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Y – Yellow |
RH – Right Hand |
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able to complete feeding. |
EDEMA |
CRY |
G – Green |
LH – Left Hand |
3 Initially slow to start or passive; has |
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G – Generalized |
L - Lusty, |
BRB – Bright Red Blood |
RW – Right Wrist |
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challenges (with |
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Ex – Hands and Feet |
Vigorous |
P – Plugs |
LW – Left Wrist |
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coordination, resp. effort, color, tone, |
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PO – Periorbital |
W - Weak |
Br – Brown |
RAk – Right Ankle |
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posture or state); needs support |
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Hi - |
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LAk – Left Ankle |
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throughout and may or may not |
ABDOMINAL |
A - Appropriate |
ASPIRATE TYPE |
S – Scalp |
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complete feeding. |
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S – Soft |
for age |
M – Mucous |
B – Broviac |
4 |
Initially energetic or slow to start; |
|
ND – |
F – Formula |
PQ – |
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becomes disorganized; shows |
||
Ts – Tense |
Q - Quiet |
B – Bilious |
|
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instability (in |
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Tn – Tender |
|
FB – Frank Blood |
BLOOD GAS SITE |
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coordination, resp. effort, color, tone, |
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DC – Discolored |
PAIN SCREEN |
CG – Coffee Ground |
HS – Heel Stick |
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posture or state); is unable to complete |
|
D – Distended |
pain screen |
A – Air |
VS – Venous Stick |
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F – Full |
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FS – Finger Stick |
5 |
(*) Concerning feeding behaviors or |
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DISPOSITION |
Art – Arterial Stick |
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oral motor patterns; may appear |
BOWEL SOUNDS |
*Refer to pain |
A – Aspirate |
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disinterested or upset with feeding |
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- Absent |
assessment |
D- Discarded |
CIRC |
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attempts or may awaken but is unable |
+ |
- Present, Active |
scale |
R- Ref |
CL – Clean |
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to coordinate |
- Decreased |
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DG – Drainage |
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- Hyperactive |
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BL - Bleeding |
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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
SP - Sidelying Position
OP - Other Position
CS - Chin/Cheek Support
OX - Oxygen
EN - Environment
Other - Specify
TYPE OF NIPPLE |
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Y - Yellow |
SF- Slow Flow |
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R - Red |
P - Playtex |
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N - Nuk |
H - Haeberman |
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G – Gerber Premie |
SL=Slit |
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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:
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ENTERAL INTAKE |
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PARENTERAL INTAKE |
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OUTPUT |
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MODE |
TOTAL |
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E |
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URINE |
STOOL |
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M |
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AMT |
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ASP |
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Dext% |
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IL |
Total |
Site |
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COLOR |
M |
R |
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CONSIS |
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AMT |
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M |
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I |
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Type |
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U |
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S |
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L |
RATE |
Hourly |
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Rate |
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A |
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Bolus |
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URINE |
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Hourly |
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W/STOOL |
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Rate |
Hourly |
Location |
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FORMULA
SUPPLEMENTS
FORMULA TYPE/CALORIE
#1__________________________
#2__________________________
#3__________________________
ORAL (PO) FEEDING DESCRIPTION * See Codes
T |
Behavior |
Attempt |
Behavior |
Response |
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Type |
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I |
Before |
PO |
During |
to |
Duration |
Supports |
of |
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Feeding |
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Feeding |
Y/N |
Feeding |
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Nipple |
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COMMENTS:_______________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Eff. 9/1/11 Rev. |
Page 4 of 4 |