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Download Terry - ICU Daily Two - Center for Patient Safety
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Acrobat Reader 4.x required! Click here or go to www.adobe.com to download. Henry Ford Hospital ICU Daily Goal / Communication Sheet Resident Pager #_______________ Date: 1 17 POD Room Jan 2 Feb 3 Mar 4 5 18 19 20 21 1 1 2 2 3 3 4 4 Apr 6 22 5 5 Respiratory Pager #_______________ May 7 8 9 23 24 25 6 6 June 7 8 July 10 26 9 Aug Sep 11 12 13 27 28 Oct 14 29 Nov Dec 15 16 30 31 10 Patient Daily Goals: Step(s) we need to take to ready pt for transfer out of the ICU Daily Goals Met Not Met Met Not Met Met Not Met Met Not Met Met Not Met Tests / Procedures scheduled today Completed Not Completed Completed Not Completed Completed Not Completed Completed Not Completed What actions need to be taken today to get this patient out of the ICU? What is this patient's most significant safety risk? DVT Prophylaxis? Is Pt Vented? HOB @ 30 Degrees PUD Prophylaxis SBT Plateau < 30 Is mouth care being done Q 2 hours? Yes Yes Yes Yes Yes Yes Yes No No No No No No No N/A N/A N/A Yes No Pt on sedation? Yes No If yes, was patient able to follow commands? Yes No If unable to follow commands, was a daily sedation vacation done? A-line SG Cath Central line(other than SG) Does Pt have a central / arterial line? Yes No Have tubes, lines and pacing wires been reviewed for removal? Yes No Does Pt have Foley catheter? Yes No Yes No Is the patient getting scheduled labs? (i.e. Q6, Q4) Are scheduled labs necessary? Yes No Was family updated yesterday on pt's condition? N/A N/A IABP None N/A N/A Comments: 55205 T-ICU Daily Two 3/04 Pain assessed Q 4 hours? If pain medication is given was it reassessed within 1 hour? Bedrest Mobility: Up in chair OPT/OT consult Yes Yes No No N/A N/A NA Review of all IV medications for possible change to PO? Review of all home medications for possible restart? Review all cultures and assure antibiotics are appropriate (coverage and duration)? Patient is receiving appropriate level of nutritional support? Appropriate anti-platelet or anticoagulation medication? Appropriate post cardiac surgery medications (Beta Blocker, Ace inhibitor)? Yes Yes Yes Yes Yes Yes No No No No No No N/A N/A Team members present and reviewed goals: Day Nurse Night Nurse Charge Nurse Nurse manager/CNS Fellow Resident Faculty Rounder Pharmacy Respiratory SW/DC planning PT/OT/Speech Path Nutrition Physician Assistant Family Comments: 55205
