Page 66 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 5: Preventing Morbidity in the ICU 35

Room Number _____ MD/NP COVERING patient today: Date
____/____/____
PM shift (7PM)
AM shift (7AM)
**Note Changes from AM**
What needs to be done for the patient
to be discharged from the ICU?
Safety Patient’s greatest safety risk?
How can we decrease risk?
What events or deviations need
to be reported?
Pain Management/Sedation Pain goal ____/10 w/___RASS goal ___w/____ Wean sedation for extubation in AM
Daily lightening of sedation
• CAM-ICU if not provider should document why not
• Qualify for PAD protocol? CAM ICU Positive Negative
• Qualify for AWS protocol? AWS admission screen Positive Negative
Cardiac HR goal_______ At goal
• Review ECGs ß Block_________
Volume Status Net even Net positive
Net neg: ____ w/_______
• Net goal for midnight Pt determined
Pulmonary OOB/ pulm toilet/ambulation Wean vent (_ __SBT)
Ventilator: (HOB Maintain current support Mechanics by __AM
Fi <_____ PEEP < ____
Plan to extubate
elevated, Oral care q4), Wean as tol (_ _SBT) Swallow Eval
O 2
RTW/weaning PS/Trach trial ___h x ____ Mechs before/after
SIRS/Infection/Sepsis Evaluation No current SIRS/sepsis issues
Patient Care Temp > 38°C or < 36°C < 32 torr PAN Cx Bld x2 Urine AG Levels:
Known/suspected infection:
SIRS Criteria
Other
Sputum
HR > 90 BPM
ABX changes: Initiate/D/C
RR > 20 b/min or Pa
CO 2
WBC > 12K < 4K or > 10% bands
Y Sepsis Bundle
N
Can catheters/tubes/lines be If foley cannot be removed provider must document a
removed/rewired? note why not
GI/Nutrition/Bowel Regimen NPO TF Type______goal _____
(TPN line, NDT, PEG needed?) TPN INSULIN REQ__________Adj needed y/n
Is this patient receiving DVT/PUD DVT: Hep q8/q12/gtt (protocol?) PUD: PPI
H B
TEDS/SCDs
prophylaxis? LMWH 2
Anticipated LOS >72hours: Fluconazole prophylaxis
fluconazole PO N/A
Can any meds be discontinued, N/A PO:
D/C:
converted to PO, adjusted? Renal: Liver:
Tests/Procedures/OR Today N/A Consents needed/obtained Line change
Scheduled Labs N/A
(Reassess need q12h)
CMP BMP H8 Coags ABG
Planned AM labs
To Do CXR? Lactate Core 4
CXR
Restraints Ordered
Order for restraints?
Wed: Transferrin Iron Prealb 24h urine
Y N
Consultations Does pt meet criteria for mobility protocol?
PT/OT/SLP consult
Is the primary service up -to-date? Y N
Disposition Has the family been updated? Y N Family meeting today?
Social issues addressed
N
N/A
Y
(LT care, palliative care)
Rev 11.07.12

ICU status: ___ IMC status: vitals q ______ Fellow/Attending Initials: ______ Nursing Initials: ______
FIGURE 5-2. Example of a daily goals sheet for use during multidisciplinary rounds in the ICU. The goals sheet is completed to operationalize the plan for each patient day, and kept at the
patient bedside for easy availability to all providers. Progress toward goals can be benchmarked throughout the day.
Unfortunately, methods to measure diagnostic errors are under- for misdiagnosis at the patient, organizational, or provider level are
developed and most studies measuring patient safety ignore diag- incompletely defined, and little information exists on the root causes
nostic errors. Practical solutions to reduce diagnostic errors have of misdiagnosis in the ICU. One risk factor for some types of ICU
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also lagged behind those in other areas of safety. Risk predictors misdiagnosis is during off hours (eg, nighttime) when physicians

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