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					U N I V ER SIT Y OF V IRGIN I A HE A LT H SYST EM                                                                             PLACE LABEL HERE.

                                                                                                                         FEBRUARY 2008
                                                                                                                         FORM NO. 020220
                    1000000                                                                                     IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#


CRITICAL CARE SYSTEMS ASSESSMENT — MICU — Check boxes that apply. Add comments prn.
DATE: _______________________             TIME: _____________________

NEUROLOGICAL:    o Sedated    o RASS score/goal ____/____    o Unresponsive    o Awake/Alert    o Agitated    o Chemically Paralyzed
  Oriented:  o x1  o x2  o x3                Disoriented: o occ  o freq  o totally          Follows commands  o Yes  o No
  GCS: L Pupil ______   R Pupil ______   Motor ______   Verbal ______   Eyes ______   Restraints: ________________________________________
	 Protective	reflexes	intact:	 	 	o cough    o gag    o blink
  Movement and sensation:    o intact all 4 extremities    impaired (describe) _________________________________________________________
   ___________________________________________________________________________________________________________________________
  Comments:                                                                                                                             


PAIN ASSESSMENT: Current Pain Management:               N/A  
                                                       o              o PRN Analgesia            Scheduled Analgesia 
                                                                                                o                           o  PCA   
   
                                                        Epidural     o 
                                                       o                Non-pharmacologic        Infusion
                                                                                                o 
  Pain Scale Used:   o                                Numeric Rating Scale  o 
                           Verbal Descriptive Scale  o                         Visual Analogue Scale  o  ModFlacc
  Is the patient currently having pain?       o         No, pain not an issue    o 
                                                Yes    o                              No, pain management effective
  Location/radiation of pain: ___________________________________________________ Pain rating:                       Pt’s pain goal:
  Comments (describe duration and character):                                      

RESPIRATORY: o          ETT # / ______ / _______ cm @ _____   o      Trach # _______   o    Trach collar _______ %  o    SSV L/min ________
  o    Ventilator: ______  Mode: ______  FiO2:______%  Rate: ______ Set TV: ______  PEEP: _______  PS/PC:_____
  o     Room Air  o     NC L/min______  o     Mask Type/FiO2:_____________________  o             High Flow/High Humidity: FiO2 _______%  L/min _______
  Respiratory Pattern  o      unlabored        o  labored (describe) __________________________________________________________________
   o     asynchrony with ventilator  o   Breathing over set ventilator rate  o   Synchronous with ventilator
  Sputum:   o       none  o    small  o   mod  o   large  o   thick  o   thin  o  frothy  o   clear  o   white  o   yellow  o  tan  o   bloody
  Breath Sounds (describe): 
     Right  ______________________________________________________  Left  ______________________________________________________
  Chest Tube(s):  #1 site______________ o@___ cm sxn or owater seal  drainage: o          none  o    serous  o  serosanginous  o   other__________________
                     
                     #2 site______________ o@___ cm sxn or owater seal  drainage: o        none  o   serous  o  serosanginous  o   other__________________
  o     Spare tracheostomy tube or obturator at bedside    o       Resuscitation bag and mask at bedside
  Comments: 
 

CARDIOVASCULAR:   o          NSR  o   SBrady  o    STach  o  AFib  o AFlutter  o Paced   o            Other
                                                                                            Ectopy   o 
  S1S2:        o  Clear  o Distant  o             S3 
                                      Muffled	 o  o  o   S4     Rub  o Murmur  o   Click  o  Other ________________________________________
  Edema:  o       Face    o Neck  o  Upper Extremities                 o Lower Extremities                  General________________________
                                                                                                           o 
  Pulses (0-4+/Doppler)        Radial R            L             DP R           L 
	 CapRefill	 o   Pale  o  Pink  o  Dusky  o  < 3 sec.  o > 3 sec. 
  Arterial line: site___________________________________  waveform:  o         normal  o  dampened  o    positional
  Comments: See CCFS for vital signs, hemodynamic readings, and lab results 
 

IV ACCESS SITE(S): __________________________________________________________________________________________________________ 
o   PA catheter @       cm at hub
   Port:
   Infusion name:
  Concentration:
   Dose/rate:

   Port:
   Infusion name:
  Concentration:
   Dose/rate:

GASTROINTESTINAL: 
               soft  firm	 nondistended  o 
  Abdomen:  o  o  o                                      obese  Bowel Sounds:  o 
                                             distended  o                        none  o              active  o 
                                                                                         hypoactive  o         hyperactive
  Last BM (date) _______________   o   bowel management system    drainage:______________________________
  o                        blue balloon with 35-45ml H2O  o 
    red	balloon	deflated	 o                                  drainage pouch    drainage:______________________________
  Comments: 

NUTRITION:  o              npo  tube feeding  o 
                 po diet  o  o                   TPN
  Enteral Access:  o oral  o                 left 
                             nasal  nare:  o  o     right  o 
                                                            small	bore	flexible	tube	 o            PEG  o 
                                                                                       sump tube  o      PEG/J
  Comments: 

FORM # 020220        CAT: 10-FLOWSHEET               (REV. 02/08)            To reorder, log onto http://www.virginia.edu/uvaprint	              	          1 OF 2
GENITOURINARY:  o         foley  o condom catheter  o spont void  o continent  o  incontinent
  Urine:  o straw  o  yellow  o  amber  o bloody  o  clear  o cloudy
  Dialysis:  access type/site_____________________________  type:  o      continuous  o                peritoneal
                                                                                        intermittent  o 
  CRRT:  o   ports reversed  calcium______ mL/h  citrate______ mL/h  BFR______ mL/min  DFR______ mL/h
	 replacement	fluid	______________________	mL/h	 fluid	removal	______________________	mL/h	 dialysate_______________________________
  Comments: 
  
INTEGUMENTARY:  Describe drains, ostomies, wounds, breakdown, pressure sores, and ecchymosis  __________________________________ 
                                                                                                        _
  __________________________________________________________________________________________________________________________
  __________________________________________________________________________________________________________________________  
  __________________________________________________________________________________________________________________________  
  __________________________________________________________________________________________________________________________
  o Medication patch:  type ___________________  site ___________________ 
	 Diligent Equipment in Use:  o Yes  o No    Type:  o Steady  o Encore  o Tempo  o Maxi-Slides  o Transfer Tubes  o Tenor
   Specialty Bed:  o Kin Air Overlay oKin Air oBariKare oBariMax   Still Required?  oYes oNo 
  o SCDS  o Plexipulse  o RLE  o LLE  o wound vac:  sxn setting ________ mmHg  o continuous  o intermittent  drainage: __________________
  Comments: 
 
  INVASIVE LINES / WOUNDS / DRESSINGS: Invasive lines patent; sites free of sx of infection; dressings dry & intact; 
	 distal	ports	of	pressure	lines	transduced	to	standard	normal	saline	flush	with	good	waveform,	unless	otherwise	noted.
 
 
 
 
 
 
 
 
 

Braden Risk Assessment Scale: Circle: Monday Wednesday Friday Circle the number in each category; total at bottom
  SENSORY PERCEPTION  1. Completely Limited                     2. Very Limited                     3. Slightly Limited            4. No Impairment
                   MOISTURE  1. Constantly Moist                2. Very Moist                       3. Occasionally Moist          4. Rarely Moist
                     ACTIVITY  1. Bedfast                       2. Chairfast                        3. Walks Occasionally          4. Walks Frequently
                    MOBILITY  1. Completely Immobile            2. Very Limited                     3. Slightly Limited            4. No Limitations
                  NUTRITION  1. Very Poor                       2. Probably Inadequate              3. Adequate                    4. Excellent
     FRICTION AND SHEAR  1. Problem                             2. Potential Problem                3. No Apparent Problem
SCORE:                              < 19 Skin Breakdown Risk
Interventions:  o Incontinence skin cleansing/protection  o Schedule turning  o Provide pressure relief  o Facilitate Mobility  o Reduce friction/shear
Comments: 
PSYCHOSOCIAL: Able to identify needs: Yes / No                            Support Systems Identified: Yes / No
                      Concerns expressed regarding sexuality, culture, religious beliefs or ethnicity:      Yes / No
   Suicide precautions in place
Suicide Assessment: “You have been placed on suicide precautions. Do you feel like hurting yourself now?” Yes / No
Suicide interventions:        1:1 observation maintained            Constant observation maintained
Comments: 
Schmid Fall Risk Assessment Tool — Circle group number                                       Fall Risk Reduction Intervention
     MOBILITY  0 Ambulates without gait disturbance                                          o  Implement Fall Precaution Procedure
                  1 Ambulates or transfers with assist devices or                            o  Discontinue Fall Precaution Procedure
                    assistance/unsteady gait.                                                o  Communicate patient fall risk to charge nurse
                  1 Ambulates with unsteady gait and no assistance                           o  Activate bed alarm system
                  0 Unable to ambulate or transfer                                           o  Place bed in low position when patient unattended
  MENTATION  0 Alert, oriented x 3             1 Periodic confusion                          o  Frequently orient patient to call bell(s)
                  1 Confusion at all times     0 Comatose/unresponsive                       o  Recommend P.T. consult to MD
  MEDICATION  1 Anticonvulsants, tranquilizers, psychotropic, hypnotics                      o  Recommend O.T. consult to MD 
                  0 No anticonvulsants, tranquilizers, psychotropic, hypnotics
  ELIMINATION  0 Independent in elimination 
                  1 Independent with frequency or diarrhea
                  1 Needs assistance with toileting
                  1 Incontinent
  PRIOR FALL  0 No prior history               1 Unknown
      HISTORY  1 Yes, before admission (home or previous admission)
                  2 Yes, during this admission Date 
Total	Score:                  *3 or greater = FALL RISK

Comments: 

o  Physiologic Monitoring Alarms Settings Assessed and Audible      o  ID Band present and accurate

Signature _____________________________________________________________________________________________________________, RN                               2 OF 2