ICU Charting/standards of care

[OKRN]

I am just curious how often you guys are having to chart full assessments in the ICU. Also in the ICU how ofter are you required to chart I/O's?

Thanks

[augigi, CNS]

We did full assessment once per shift, unless something changed. Fluid balance every hour.

[LCRN]

At my facility we document the following routienly:

full assessment Q4 hr

lung sounds Q2 hr

vitals Q1 hr

I/O Q1 hr

hemodynamics Q4 hr (also w/ every change in vasoactive meds)

This is all subject to change depending on the patient and the circumstance- if a patient has an IABP pulse checks are done Q1, if neurosurgical patient neuro checks done Q1 and so on....

LCRN

[MarySunshine]

Neuro ICU:

Full body assessment every shift unless there's a change

Vital signs every hour

Neuro checks every hour (just orientation (GCS), pupils and movement...not every single neuro detail)

I&O's every two hours

[panamarenkot]

Our policy is full assesment Q4HR, VS QHR, but if we're infusing visoactive drugs- BP w/MAP Q15 min.

[NeoNurseTX, RN]

full assessment q shift, iv site check qh.

vitals q 3 if stable baby, q2 if on high flow o2, q1 if intubated, on pressors, has art line.

[meandragonbrett]

Assessments q2h (with system focused assessments on the opposite hour....such as vent assessment, neuro assessment, neurovascular, etc. All depending on what is going on with the paient)

Vitals q1h

I/O q1h

[Magsulfate, BSN, RN]

I work in a long term acute care ICU... We chart vitals Q1 hr and fluid balance Q1hr, pain Q1hr and narrative q2hr.. if they're on pressors or diprivan then vitals Q15 mins

[marilynmom, LPN, NP]

PICU:

Assessments q4hrs

Vitals (that includes I&Os, vent settings, gtts, etc.) for our more stable patient q1hr

Neuro q1hr

Patients that are very unstable or on pressors q15min vitals

Really, everything seems to be done q1hr for the most part....I think that is the nature of the ICU