This presentation outlines the standards of care documentation in the ICU. It covers the required assessments, monitoring, and documentation at various intervals throughout a patient's stay in the ICU.
Full physical assessment, including vital signs with temperature and pain scale. IV assessment (peripheral/central/arterial) and VTE Prophylaxis.
Tube/Drains assessment (JP, Chest tube, feeding tubes), Cardiac monitoring/alarm limits, and ICU Delirium screen.
Braden scale (pressure sore risk assessment), Morse Fall assessment/override (fall risk assessment), and Fall injury prevention.
BMAT (mobility assessment tool), Mobility (turns/HOB), Safe environment, Psychosocial, and Safety equipment at bedside.
Perform a focused assessment, which may use reassessment - "unchanged from previous full shift assessment" if applicable.
Check and document vital signs with temperature and pain scale.
Conduct Tube/Drains assessment and IV assessment.
Ensure care plan is documented/evaluated each shift and education performed/documented each shift.
Perform a focused assessment, which may use reassessment - "unchanged from previous full shift assessment" if applicable.
Check and document vital signs with temperature and pain scale.
Conduct Tube/Drains assessment and IV assessment.
Perform Morse fall assessment/override and implement Fall injury prevention measures.
Check and document vital signs with pain scale (numerical or NVPS) every hour.
Monitor and record Intake and Output (rate dose verify/urine output/tube feeds) every hour.
Check mobility - turns self vs q2 for immobile patients *movement of devices (SpO2, ETT)
Perform peripheral IV assessment (if continuous drips running)
Provide q2 oral care for ventilated/BIPAP/NPO status patients
ICU Standards of Care Documentation