The SOAPnote Project > Complete Note > ICU

ICU

By 1976ericharris

posted 2020-02-03, updated 2021-07-10

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Room Number: [text name="variable_1" default=""]
SUBJECTIVE: [comment memo="Age"][text name="variable_2" default=""]y/o[comment memo="Sex"][checkbox name="variable_3" value="Male |Female "]with a PMH of:[textarea name="variable_4" default=""]
HPI: 
[comment memo="Two liner summary with where they presented and with what complaints."]
[textarea name="variable_47" default=""]
ED Course:
[comment memo="Labs, Radiology, Micro"]
[textarea name="variable_48" default=""]
[checkbox name="variable_26" value="-Pt exterminated and evaluated during multidisciplinary rounds with ICU team and Dr. Alnajjar Mahafzah. Chart reviewed: including labs, imaging, diagnostic workups, and consult notes. Assessment and plan created, discussed and planned by Dr. Alanajjar Mahafzhh. |Per nursing no acute overnight events |Per nursing acute overnight events (described below) |-Pt remains on mechanical ventilation "]
[textarea name="variable_5" default=""]
Intake and Output:
[textarea name="variable_70" default=""]
Respiratory: 
[textarea name="variable_71" default=""]
[checkbox name="variable_6" value=" Date Arrived to: ED |Date Arrived to: Hospital "]
[text name="variable_7" default=""]
Since being in ICU: 
[textarea name="variable_9" default=""]

Physical:
Vitals: Temp:[text name="variable_65" default=""] HR:[text name="variable_66" default=""] RR:[text name="variable_67" default=""] BP:[text name="variable_68" default=""]
General:[checkbox name="variable_10" value="Intubated on Mechanical Ventilator| Intubated via Endotracheal Tube| Ill Appearing| No outward distress| WDWN| Obese "][textarea name="variable_18" default=""]
HEENT:[checkbox name="variable_11" value="EOMI| MMM| Neck supple| Trachea midline"][textarea name="variable_19" default=""]
Cardiac:[checkbox name="variable_12" value="RRR| Tachycardia| Bradycardia| No Murmurs| No Rubs| No Gallops| Irregular Irregular Rhythm"][textarea name="variable_20" default=""]
Respiratory:[checkbox name="variable_13" value="CTAAF with equal breath sounds b/l| Diminished breath sounds b/l| Air entry equal bilaterally| Intubated on mechanical ventilation| No wheezing| No rales| No rhonchi| Coarse breath sounds"] SiO2%:[text name="variable_27" default=""]
[textarea name="variable_21" default=""]
Abdominal:[checkbox name="variable_14" value="To visual inspection no scars, rashes, or masses| To auscultation bowel sounds present in all four quadrants| To palpitation abd is soft with no tenderness to palpitation, no hepatosplenomegaly, no pulsitile masses| Negative Murphy's| Negative McBurney's tenderness| Negative Rovsing's| Negative Rebound tenderness| Negative CVA tenderness"][textarea name="variable_22" default=""]
Neurological:
[checkbox name="variable_1" value="CNII-XII intact| UE DTR 2/4| LE DTR 2/4 | UE sensation intact| LE sensation intact | Negative Rhomberg| Negative Babinski's| Negative Pronatator Drift| No cerebellar deficit noted"]
[textarea name="variable_45" default=""]
Musculoskeletal: 
[checkbox name="variable_76" value="UE strength 5/5| LE strength 5/5"]
[textarea name="variable_46" default=""]
GU: Urine Color is [textarea name="variable_28" default=""]
[textarea name="variable_29" default=""]
Skin:[checkbox name="variable_15" value="Warm| Dry| Intact Skin| No rashes| No lesions"]
[textarea name="variable_23" default=""]
Extremities:[checkbox name="variable_16" value="Pules present b/l in UE| Pulses present b/l in LE| No clubbing| No cyanosis| No Peripheral Edema"]
[textarea name="variable_24" default=""]
Psych:[checkbox name="variable_17" value="Unable to assess |Cooperative |Normal Affect"]
[textarea name="variable_25" default=""]
[comment memo="Tests"]
[checkbox name="variable_31" value="Lab Results"]
Glucose:[text name="variable_32" default=""] Na:[text name="variable_33" default=""] K:[text name="variable_34" default=""]Cl:[text name="variable_35" default=""] CO2:[text name="variable_36" default=""] AGAP:[text name="variable_37" default=""] Ca:[text name="variable_38" default=""] BUN[text name="variable_39" default=""] Cre:[text name="variable_40" default=""] Alb:[text name="variable_41" default=""] WBC:[text name="variable_72" default=""] Hgb:[text name="variable_73" default=""] Hct:[text name="variable_74" default=""]
[checkbox name="variable_42" value="Radiology Results"]
[textarea name="variable_43" default=""]
Medications: 
[textarea name="variable_75" default=""]

Assessment:
#
#
#
[textarea name="variable_64" default=""]
[checkbox name="variable_52" value="H/O"]
[textarea name="variable_58" default=""]
[checkbox name="variable_53" value="H/O"]
[textarea name="variable_59" default=""][checkbox name="variable_54" value="H/O"]
[textarea name="variable_60" default=""][checkbox name="variable_55" value="H/O"]
[textarea name="variable_61" default=""][checkbox name="variable_56" value="H/O"]
[textarea name="variable_52" default=""][checkbox name="variable_57" value="H/O"]
[textarea name="variable_63" default=""] 
Plan:

[comment memo="PLAN FOR NEW ADMIT WITH A DRIP"]
[checkbox name="variable_51" value="
-ADMIT TO ICU
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE.
|-ADMIT TO ICU
-C/W MECHANICAL VENTILATION
-SBT/VENT WEANING PROTOCOL WHEN APPROPRIATE AND AS TOLERATED
-C/W PROPOFOL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-C/W FENTANYL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-DAILY SEDATION VACATION
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE."]

Room Number:
SUBJECTIVE: Agey/oSex Male Female with a PMH of:

HPI:
Two liner summary with where they presented and with what complaints.

ED Course:
Labs, Radiology, Micro

-Pt exterminated and evaluated during multidisciplinary rounds with ICU team and Dr. Alnajjar Mahafzah. Chart reviewed: including labs, imaging, diagnostic workups, and consult notes. Assessment and plan created, discussed and planned by Dr. Alanajjar Mahafzhh. Per nursing no acute overnight events Per nursing acute overnight events (described below) -Pt remains on mechanical ventilation

Intake and Output:

Respiratory:

Date Arrived to: ED Date Arrived to: Hospital

Since being in ICU:

Physical:
Vitals: Temp: HR: RR: BP:
General: Intubated on Mechanical Ventilator Intubated via Endotracheal Tube Ill Appearing No outward distress WDWN Obese

HEENT: EOMI MMM Neck supple Trachea midline

Cardiac: RRR Tachycardia Bradycardia No Murmurs No Rubs No Gallops Irregular Irregular Rhythm

Respiratory: CTAAF with equal breath sounds b/l Diminished breath sounds b/l Air entry equal bilaterally Intubated on mechanical ventilation No wheezing No rales No rhonchi Coarse breath sounds SiO2%:

Abdominal: To visual inspection no scars, rashes, or masses To auscultation bowel sounds present in all four quadrants To palpitation abd is soft with no tenderness to palpitation, no hepatosplenomegaly, no pulsitile masses Negative Murphy's Negative McBurney's tenderness Negative Rovsing's Negative Rebound tenderness Negative CVA tenderness

Neurological:
CNII-XII intact UE DTR 2/4 LE DTR 2/4 UE sensation intact LE sensation intact Negative Rhomberg Negative Babinski's Negative Pronatator Drift No cerebellar deficit noted

Musculoskeletal:
UE strength 5/5 LE strength 5/5

GU: Urine Color is

Skin: Warm Dry Intact Skin No rashes No lesions

Extremities: Pules present b/l in UE Pulses present b/l in LE No clubbing No cyanosis No Peripheral Edema

Psych: Unable to assess Cooperative Normal Affect

Tests
Lab Results
Glucose: Na: K:Cl: CO2: AGAP: Ca: BUN Cre: Alb: WBC: Hgb: Hct:
Radiology Results

Medications:

Assessment:
#
#
#

H/O

Plan:

PLAN FOR NEW ADMIT WITH A DRIP

-ADMIT TO ICU
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE.
-ADMIT TO ICU
-C/W MECHANICAL VENTILATION
-SBT/VENT WEANING PROTOCOL WHEN APPROPRIATE AND AS TOLERATED
-C/W PROPOFOL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-C/W FENTANYL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-DAILY SEDATION VACATION
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE.