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Date: ___________Shift: ___________Nurse: ___________

NursingWorksheets.comICU / Critical Care

PATIENT 1

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0800	0900	1000	1100	1200	1300	1400	1500	1600	1700	1800
HR
BP
RR
Temp
SpO2
Pain

HEMODYNAMICS

Art Line:

CVP:

PA/PCWP:

CO/CI:

SVR:

ScvO2:

VENTILATOR

Mode: ____

Rate: ____

TV: ____

FiO2: ____

PEEP: ____

PIP: ____

DRIPS / GTTS

Drug	Conc	Dose	Rate

SEDATION

RASS Goal: ____

RASS Actual: ____

CPOT/BPS: ____

Sedation Vac: ____

LINES / DRAINS / TUBES

CODE STATUS: ______________________

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

PATIENT 2

Name:

Rm: ____

Age: ____

Allergies:

Code: ____

MD:

Dx:

VITALS

	0700	0800	0900	1000	1100	1200	1300	1400	1500	1600	1700	1800
HR
BP
RR
Temp
SpO2
Pain

HEMODYNAMICS

Art Line:

CVP:

PA/PCWP:

CO/CI:

SVR:

ScvO2:

VENTILATOR

Mode: ____

Rate: ____

TV: ____

FiO2: ____

PEEP: ____

PIP: ____

DRIPS / GTTS

Drug	Conc	Dose	Rate

SEDATION

RASS Goal: ____

RASS Actual: ____

CPOT/BPS: ____

Sedation Vac: ____

LINES / DRAINS / TUBES

CODE STATUS: ______________________

MEDICATIONS

Drug / Dose / Route	Time	Given	Notes

LABS

Na:

BUN:

Cr:

Glu:

WBC:

Hgb:

Plt:

Other:

IV ACCESS

Site/Gauge:

Fluid/Rate:

Date:

I&O

INTAKE

PO:

IV:

Blood:

Other:

Total:

OUTPUT

Urine:

Drain:

Emesis:

Other:

Total:

ASSESSMENT

PLAN / TASKS

NOTES

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