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?): ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2150 Critical Care Prelab
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Patient Care
What S/S should you be on alert for and what assessments will you do?
______________________________________________________________________________
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Nursing interventions already implemented.
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Teaching
Describe the teaching that needs to be completed (Include discharge teaching).
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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.__________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Diagnostic tests R/T the signs/symptoms or manifestations of client’s condition.
Name /Type of Test
Date of Test
Findings/Results/Impression
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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
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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
2150 Critical Care Prelab
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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
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IV MEDICATION SHEET
Primary Maintenance IV fluids currently running and rate: 1) _____________________ 2) ________________________
Example: 1) Dextrose 5% and 45% Normal Saline (D51/2 NS) @ 100ml/hr
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?)
2) Normal Saline @ 10ml/hr (TKO)
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
What IV medications
this patient is getting
that is NOT compatible
with this IV
Medication?
(list each # from above)
(list these IV meds in this box)
Make additional Copies if Needed
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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)
Temp:
Pulse:
BP:
Respirations:
SaO2:
Vital Signs:
(end-shift)
Temp:
Pulse:
BP:
Respirations:
SaO2:
Vital Signs:
(mid-shift)
Pulse:
BP:
Respirations:
SaO2:
Additional Comments:
Treatments
Oxygen Therapy:
Type:
# of liters or FiO2%:
ET
Trach
Bi-Pap:
Settings:
FiO2:
Continuous
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 ___________________
Intake @ 1400:
Oral ________
IV ________
Enteral Feeding ________
Other __________
___________
Other__________
___________
Other__________
___________
Output @ 1400:
Void ________________
Foley ________________
Drains _______________
Other _________
_________
Other _________
_________
Rectal tube_________________
Total Input
Total Output ______________
_________________
Activity Order:
Telemetry Rhythm: 0800:
Additional Comments:
Psychosocial Assessment
Affect:
Additional Comments:
1000:
NOC
PRN
12:00
Drains:
CT: # ________ location__________
JP: #_______location_____________
Wound vac Location______________
Other: ____________________
Tubes: NG OG JT FT
Clamped
continuous sx
Intermittent sx
other________
Ancillary Services:
PT/OT
ST
Dietary
Social Svcs
Other _______________
1400:
Behavior:
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Physical Assessment
Pain Assessment
Neurological Assessment
Location of Pain:
Oriented to:
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
Intensity of Pain:
Duration of Pain:
Sensation:
Person
to light
L:
Sluggish
Brisk
Absent
Pain Scale:
Additional Comments:
Musculoskeletal Assessment
Cardiovascular Assessment
History of Falls:
Rhythm:
Regular Regular-Irregular Irregular-Regular
ROM:
Limited
Full
Contracted
Active
Passive
Strength:
Strong
Weak
Fatigues easily
Hand Grasps:
Left:
Strong Weak
Right: Strong Weak
None
None
Leg Movement:
Left:
Strong Weak
Right: Strong Weak
Murmur:
Bruit:
Yes
Yes
No
No
Capillary Refill:
LUE: <2 sec <3 sec
RUE: <2 sec
<3 sec
LLE:
<2 sec <3 sec
RLE:
<2 sec <3 sec
>3 sec
>3 sec
>3 sec
>3 sec
>5 sec
>5 sec
>5 sec
>5 sec
Radial Pulse:
None
None
left: Strong
right: Strong
Weak Present with Doppler Absent
Weak Present with Doppler Absent
Pedal Pulse:
Additional Comments:
left: Strong
right: Strong
Weak Present with Doppler Absent
Weak Present with Doppler Absent
Integumentary Assessment:
Edema: Present
LUE: 1+ 2+ 3+
RUE: 1+ 2+ 3+
LLE: 1+ 2+ 3+
RLE: 1+ 2+ 3+
Color:
Normal for Race
Cyanotic
Flushed
Pale
Other (describe)
Temperature: Warm
Cool
Skin:
Dry
Moist
Other(describe):
Not Present
Weeping
4+ Pitting Non-Pitting
4+ Pitting Non-Pitting
4+ Pitting Non-Pitting
4+ Pitting Non-Pitting
Clammy
Additional Comments:
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Respiratory Assessment
Gastrointestinal Assessment
Rhythm:
Bowel Sounds:
RUQ: Normal
Hyperactive
RLQ:
Hyperactive
Effort:
Regular
Ventilator
Irregular
Labored
Unlabored
SOB
Dyspnea on Exertion
Ventilator
LUQ:
Rate:
Tachypnea
Bradypnea
Apnea
LLQ:
Lung Sounds:
Anterior:
RUL______________________________
RLL______________________________
RML_____________________________
LUL______________________________
LLL ______________________________
Posterior:
RUL ______________________________
Hypoactive
Absent
Normal Hypoactive
Absent
Normal Hypoactive
Absent
Normal Hypoactive
Absent
Hyperactive
Hyperactive
BM: Last:
Abdomen:
Soft
Firm
Round
Tender
Non-tender
Mode of Elimination: Bedpan BSC BR
Rectal Tube Stoma
Other: ________
_______________________________________
Urinary Assessment
Voiding:
No difficulty
Frequency
Hesitancy
Unable to Void
RLL _______________________________
Color:____________ Appearance:__________
LUL ______________________________
LLL _______________________________
Other: Stridor
Rub
Other:__________
Additional Comments:
Wounds Assessment # 1
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
Additional Comments:
Mode of Elimination:
BRP
BSC
Bedpan/Urinal
Foley/Other Catheter
Incontinent
Wounds Assessment #2
Type:
Location of Wound:
Length:
Width:
Depth:
Drainage:
Dressing:
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)
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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.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Shift Assessment Documentation
(i.e. how this client’s assessments cares would be documented on paper)
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