METROPOLITAN COMMUNITY COLLEGE

ICU Prelab/Critical Thinking Tool

To be completed for EACH assigned patient.

STUDENT NAME ______COURSE ______CLINICAL DATE ______

Client’s Initials ______Room ______Code Status ______

Allergies ______

Sex ____ Age ____ Marital Status ______Religion ______Occupation ______

Physician(s)______

List specialty (if numerous assigned physicians)

Chief Complaint: ______

Primary Diagnosis:______

Secondary Diagnosis (if any): ______

Past Medical History ______

______Past Surgical History (if any) ______

______

  • Signs/symptoms noted on arrival to the hospital. (In addition to chief complaint):

______

______

  • Additional manifestations occurring during hospitalization:

______

  • Pathophysiology/Signs and Symptoms of the current medical condition: (Why are they in the ICU?): ______

______

Patient Care

  • What S/S should you be on alert for and what assessments will you do?

______

  • Nursing interventions already implemented.

______

Teaching

  • Describe the teaching that needs to be completed (Include discharge teaching).

______

Other Considerations

Impact of Illness

  • What is the impact of the illness on the client and his/her family? Describe ways to help patient/family Cope.______

______

  • Diagnostic tests R/T the signs/symptoms or manifestations of client’s condition.

Name /Type of Test / Date of Test / Findings/Results/Impression

Laboratory Values/Diagnostic Test Results

Laboratory/Diagnostic Test / Date of Test / Normal Values / Client Values / Relationship/Correlation to Client
What is causing this result for this client?

Make additional copies if needed

2150 Critical Care Prelab 1

Medication Information Sheet

List first the medications you will administer, then PRN medications, then other medications client will receive.

Drug Name / Classification / Dose, Route, Frequency / Action / Use for This Client / Side Effects / Interactions / Nursing Considerations
administration concerns

Make additional copies if needed
Medication Information Sheet (cont’d)

Drug Name / Classification / Dose, Route, Frequency / Action / Use for This Client / Side Effects / Interactions / Nursing Considerations
administration concerns

Make additional copies if needed

IV MEDICATION SHEET

Primary Maintenance IV fluids currently runningand rate: 1)______2) ______

Example: 1) Dextrose 5% and 45% Normal Saline (D51/2NS) @ 100ml/hr 2) Normal Saline @ 10ml/hr (TKO)

Name of Medication and dose
(in type and amt of ml when applicable) / Amount and Type of Diluent
(if medication needs to be reconstituted or diluted) / Rate of administration(How fast will you give it?) / How is this IV Medication to be given to patient?
(IV Push, IV drip, IV Piggyback [Secondary]) / Is this IV Medication compatible with your Primary Maintenance IV Fluids?
Y / N
(list each # from above) / What IV medications this patient is getting that is NOT compatible with this IV Medication?
(list these IV meds in this box)

Make additional Copies if Needed

2150 Critical Care Prelab 1

Client Assessment

To be completed on clinical day.

Clinical Date: ______

General Information: (Circle or fill in)

Diet: / NPO:
Enteral TPN PPN / Enteral Type:
Rate: / TPN rate:
PPN rate:
Vital Signs:
(beginning of shift)
Temp:
Pulse:
BP:
Respirations:
SaO2: / Vital Signs:
(mid-shift)
Pulse:
BP:
Respirations:
SaO2: / Vital Signs:
(mid-shift)
Temp:
Pulse:
BP:
Respirations:
SaO2: / Vital Signs:
(end-shift)
Temp:
Pulse:
BP:
Respirations:
SaO2:
Additional Comments:

Treatments

Oxygen Therapy:
Type:
# of liters or FiO2%:
ET Trach / Bi-Pap:
Settings:
FiO2:
Continuous NOC PRN / Drains:
CT: # ______location______
JP: #______location______
Wound vac Location______
Other: ______
Ventilator Settings:
Tidal Volume: ______
Mode: A/C rate ______or CPAP
PEEP ______or PS ______
FiO2% ______
ET Tube size: Location: / Treatments:
SCD’s Plexi pulse TEDS
Heating blanket IS cooling blanket HOB >30
Other ______
Other ______/ Tubes: NG OG JT FT
Clamped continuoussx
Intermittent sx other______
Intake @ 1400:
Oral ______
IV ______
Enteral Feeding ______
Other ______
Other______
Other______
Total Input ______/ Output @ 1400:
Void ______
Foley ______
Drains ______
Other ______
Other ______
Rectal tube______
Total Output ______/ Ancillary Services:
PT/OT
ST
Dietary
Social Svcs
Other ______
Activity Order:
Telemetry Rhythm:0800: 1000: 12:00 1400:
Additional Comments:

Psychosocial Assessment

Affect: / Behavior:
Additional Comments:

Physical Assessment

Pain Assessment
Location of Pain:
Intensity of Pain:
Duration of Pain:
Sensation:
Pain Scale: / Neurological Assessment
Oriented to: Person Place Time
Event
Disorientated to: Person Place Time
Event
Pupils:
Size: R: 1 2 3 4 5 L: 1 2 3 4 5
Response: R: Sluggish Brisk Absent
to light L: Sluggish Brisk Absent
Additional Comments:
Musculoskeletal Assessment
History of Falls:
ROM: Limited Full Contracted
Active Passive
Strength:
Strong Weak Fatigues easily
Hand Grasps:
Left: Strong Weak None
Right: Strong Weak None
Leg Movement:
Left: Strong Weak None
Right: Strong Weak None / Cardiovascular Assessment
Rhythm:
Regular Regular-Irregular Irregular-Regular
Murmur: Yes No
Bruit: Yes No
Capillary Refill:
LUE: <2 sec <3 sec >3 sec >5 sec
RUE: <2 sec <3 sec >3 sec >5 sec
LLE: <2 sec <3 sec >3 sec >5 sec
RLE: <2 sec <3 sec >3 sec >5 sec
Radial Pulse:
left: Strong Weak Present with Doppler Absent right: Strong Weak Present with Doppler AbsentPedal Pulse:
left: Strong Weak Present with Doppler Absent right: Strong Weak Present with Doppler Absent
Edema: Present Not Present Weeping
LUE: 1+ 2+ 3+ 4+ Pitting Non-Pitting
RUE: 1+ 2+ 3+ 4+ Pitting Non-Pitting
LLE: 1+ 2+ 3+ 4+ Pitting Non-Pitting
RLE: 1+ 2+ 3+ 4+ Pitting Non-Pitting
Additional Comments:
Integumentary Assessment:
Color:
Normal for Race Cyanotic
Flushed Pale
Other (describe)
Temperature: Warm Cool
Skin: Dry Moist Clammy
Other(describe):
Additional Comments:
Respiratory Assessment
Rhythm: Regular Irregular
Ventilator
Effort: Labored Unlabored SOB
Dyspnea on Exertion Ventilator
Rate: Tachypnea Bradypnea Apnea
Lung Sounds:
Anterior:
RUL______
RLL______
RML______
LUL______
LLL ______
Posterior:
RUL ______
RLL ______
LUL ______
LLL ______
Other: Stridor Rub Other:______/ Gastrointestinal Assessment
Bowel Sounds:
RUQ: Normal Hypoactive Hyperactive
Absent
RLQ: Normal Hypoactive Hyperactive
Absent
LUQ: Normal Hypoactive Hyperactive
Absent
LLQ: Normal Hypoactive Hyperactive
Absent
BM: Last:
Abdomen: Soft Firm Round
Tender Non-tender
Mode of Elimination: Bedpan BSC BR
Rectal Tube Stoma Other: ______
______
Urinary Assessment
Voiding: No difficulty Hesitancy
Frequency Unable to Void
Color:______Appearance:______
Mode of Elimination:
BRP BSC Bedpan/Urinal
Foley/Other Catheter Incontinent
Additional Comments:
Wounds Assessment # 1
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing: / Wounds Assessment #2
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Additional Comments:

Environmental Safety

Side rails: Down 1 Up 2 Up 3 Up 4 Up
Bed Position: Low High Bed Locked: Yes No
Restraints: Type: Location of restraints:
Assess and Document: q 15 min (Behavioral) q 2 hrs(medical management)

Nursing Diagnosis

□What is this client’s priority nursing diagnosis for this shift?

(Problem R/T______AEB______)

______

□What is the goal for this client with regards to his/her condition? (SMART Goal)

Client will:

______

□List 5 nursing interventions and rationales for this client in order to meet this goal.

Interventions Rationale

□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal could be revised.)

______

Shift Assessment Documentation

(i.e. how this client’s assessments cares would be documented on paper)

______

2150 Critical Care Prelab 1