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NICU Report Sheet

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mandyfam24
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812 views1 page

NICU Report Sheet

Uploaded by

mandyfam24
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient: Parents: Delivery:

❑ Vag ❑ C/S ❑ Breech ❑ Vac ❑ GBS ❑ Surf ❑ Beta ❑ Mag


DOB: GA: CGA: DOL:
G: P: Apgars. NBS_______ ❑ Vit K ❑ Erythro
BW: CW: DCW: ISO: HX / DX:

✜ RESPIRATORY

❑ RA ❑ NC ❑ HFNC ❑ NON-INV NAVA LEVEL __________ ✤ FEED


❑ NIMV ❑ SIMV ❑ HFOV ❑ 8/11/2/5 ❐ 9/12/3/6
Device: _______________ ❑ MBM ❑ DBM ❑ Formula ___________ Vol: __________ Cal: ___________
ETT: ________ Fr@ ______ cm Sx depth: _______ Trach: __________ PO amt / Ad Lib: ______________________ Shift Min: ________________________
TCM/EtCO2: _____________ Proclata Cr /Liq Prot: _________________
RATE/HZ: ________________ iNO: _______________________________________ NGT OG R/ GTT @ _____________________ Placed on:
PIP/MAP: ________________ Sounds/Effort: ___________________________ ______________________
DeltaP: __________________ FiO2: ______________________________________ Infuse Over: ___________________________ Nipple Type: ___________________
PEEP/AMPS: ____________ Secretions: _______________________________ Emesis : Y N Reflux: Y N Residuals: _____________________
CXR: _____________________ Goal Stats: ________________________________
Adequate BM Supply: Y N
Nipple/Positioning: ____________________ Girth: _________________
pH PaCO2 PaO2 HCO 3 _____________________________________________________________________________
7.35 - 7.45 35 - 45 80 - 100 21 - 27

♡ SKIN/MUSCLE/WOUND
♥︎ CARDIAC Humidity % ___________________________
Isolette / Bed Change: ________________
Murmur Y N Diaper Dermatitis: Y N
Echo on: _____________________ Results: ________________________________ PT / OT: ________________________________
HR: ___________________________ PRBCs: _________________________________ Last bath: _____________________________
BP: ___________________________ FFP/PLT: _______________________________ Wound: ________________________________
___________________________________________________________________________

✔︎ Neuro ➤ GI
GTT OG R/L NGT: ________ Fr @ _________ to _________ Out: ___________
Tone:
Repogle / Salen Sump: __________ Fr @ _________ to ________ Out: ________
HUS on: __________________ Results: __________________________________
Ostomy: __________________________ Bag ▵’d: ________________ Out: ________
MRI on: __________________ Results: __________________________________
Urinary Bath: _____________________ Fr @ _________ to ________ Out: ________
ROP on: __________________ Results: __________________________________
Abd / GI: _____________________________
NPASS/NAS: _____________
Urine output / 4hrs: _____________________ Last stool: ____________________
NEURO/Bndle: ___________
_____________________________________________________________________________
PRNs: ____________________________________________________________________
___________________________________________________________________________
☢︎ LABS
Accucheck: ______________________
Last PRBC: _______________________

☆ IV ACCESS Bili: _______________________________ Photo tx: __________________________


_____________________________________________________________________________
PIV: _____________________________ PIV: __________________________________
❑ PICC ❑ BROVIAC ❑ UAC
Central placed: _________________
❑ UVC ❑ PAL ❑ IJ
⚠︎ INFECTION
Blood cx: ____________________________
Drsg ▵’d: __________________________ Cap ▵’d: __________________________
UAC @ ____________________ cm Abx: _______________________________ Day: _______________ of: _______________

VUC @ ____________________ cm MRSA / MSSA : _________________________


IV FI: __________________ %____________________ @ ___________________ ml/hr CMV: + Y N
IL/SMOF: % _______________________ gm @ ______________ ml/h _____________________________________________________________________________
GTT: ______________________________________________________________________
GTT: ______________________________________________________________________
GTT: ______________________________________________________________________
____________________________________________________________________________

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