PICU Progress Notes

[text name="variable_1" default="PICU Progress"]



Rounds With : _
Diagnosis: _

ICU Days: _
Major Events Last 24 hrs:_
Procedures Performed (if any):_


Respiratory:
Day of Ventilation:_
ETT size_ Level_
Cuffed: Y / N Cuff pressure_ Leak_
Support: NC____L/min

Vent mode _
VtSet_
Fi02_
PIP_ PEEP_ PS_ RATE_

HFOV
MAP_ AMP_ Freq_ FiO2_

Non-Invasive Ventilation
Mode: CPAP/BIPAP/HIGH FLOW NASAL CANULA
Settings:_

Extubated on:_/_/_

Vitals: RR_ Spo2_ EtCO2_
CXR:
Suctioning needs:
ABG: pH_ Pco2_ Pao2_ HC03_ BE_ Sao2_
Exam: not in respiratory distress, Air entry equal bilaterally, no crepitations, no rhonchi

Cardiovascular:
Meds/Inotropes(If Any):  _
CVP (If Any):day# _ site_
A-line(If An): day#: _ site: _
Vitals : HR_ BP/MAP'S_ CVP_ RAP_ LACTATE_SvO2_
EXAM: Hemodynamically stable, good volume peripheral pulse, Capillary Refill Time less than 2 seconds,
S1 & S2 normal, No murmur

Vital Signs (last 24 hrs)_____          Last Charted___________
Temp Tympanic                 
Heart Rate Apical                     
Resp Rate                   
SBP                      
DBP                     
SpO2                      
Weight                      
Height                     
BMI                      

Fluid/Electrolyte/ Nutrition/GI:
NPO_ Feeds / Rate_
TPN: _% Dextrose, _gm/kg/day Proteins, _gm/kg/day Fat, TPN Rate_ml/hr
Wt_ Kcal/kg/D_
Bowel Movements:_
I/O_/_ Balance_ UO_ml/kg/hr
Urinary Catheter(If Any): _Days
Drains:_
Cummulative Balance since Admission:_
Fluid status:_
Exams: soft and lax, not tender, not distended, no masses felt, no organomegaly

Labs:
Last 24 Hours




Hematology:
Transfusion(If Any): PRBC's_ PLT_ FFP_ Others__

Infectious Disease:
Tmax__ Tc__
Antibiotics(If Any):
1) _ _/_Days
2) _ _/_Days
3) _ _/_Days
4) _ _/_Days
5) _ _/_Days

Cultures(If Any):

Neurology:
Pupils: _ GCS_ ICP_ CPP_
Active Issues:
Mental Status:
Sedation level:
Exam: conscious and oriented, no focal neurological deficits, power and tone normal. Deep Tendon Reflexes normal, Pupils bilaterally equal and reactive to light

Imaging Studies(If Any):

Sedation/NMB (If Any)
Midazolam_mcg/kg/min
fentanyl __ mcg/kg/hr
Diazepam(PO/IV) _ q__hr
Lorazepam(PO/IV)_ q__hr
Methadone _q__hr
Morphine(PO/IV)_
Choral Hydrate_ q__
NMB__
Others(If Any):_
PRN(If Any):_

Musculoskeletal/Spine: normal
Skin: no visible lesions or rashes. No jaundice,normal intergrity

Lines/Access:
Peripheral Line: _Site, _Days
Central Venous Line:_Site, _Days
Arterial Line:_Site, _Days
Others:_Site, _Days

Social:
_

Assessment / plans /comments:
_