ICU Daily Goals Checklist and Plan of Care

PATIENT NAME: ______________________________________ BED# ________ Todays DATE: ______ /______/______

DD MM YYYY
Pre-round (RN and team) Round (MD and team)
Routine Practices
RN initials: ___________ Resident/MD initials: __________
Maintain same sedation
On continuous sedation? Yes No
Decrease Sedation by ______%
Sedation interruption/reduction? Yes No
COMFORT, Increase Sedation by ______%
SEDATION, Are physical restraints required? Yes No Maintain same analgesia
SAFETY Decrease Analgesia by ______%
& PROPHYLAXIS VTE Prophylaxis? Yes No Increase Analgesia by ______%
GI Prophylaxis? Yes No Above changes to target:
RASS 0 2 RASS ______
Skin or wound issues? Yes No Mobility plans reviewed? Yes No
Central line present? Yes No Continue central line? Yes No
CENTRAL LINES,
PICC? Yes No If no, new central line site
IV ACCESS,
CLA-BSI bundle in use? Yes No peripheral catheter
TUBES & DRAINS
Issues for catheters/tubes/drains? Yes No PICC
Does patient void? Yes No Goal: Negative _____ L today
Adequate urine output? Yes No Goal: Positive _____ L today
FLUID STATUS
Hemodialysis? Yes No Goal: Euvolemia CVP _____ TFI _____ ml/h
Continuous renal replacement? Yes No Change CRRT orders? Yes No
INFECTION Any new culture results? Yes No Cultures to be drawn today? Yes No
PREVENTION Culture results pending? Yes No Sputum Blood Urine Wound Other
& CONTROL Re-assess need for isolation? Yes No Antibiotics reviewed?
VAP bundle in use? Yes No No weaning
Oral care protocol q 6h? Yes No PSV Wean as tolerated
VENTILATION Is HOB elevated > 30 ? Yes No Spontaneous breathing trial today? Yes No
& WEANING Evening Rest: PSV PCV
Any reasons not to do SBT? Yes No Target SpO2: ______ %
Chest x-ray today to review? Yes No Extubate today? Yes No
Enteral or oral nutrition? Yes No NPO
Target feeds met? Yes No Enteral targets as per dietitian
Volume-based enteral nutrition Target feeds at ________ ml/h
NUTRITION
Trophic enteral nutrition Continue motility agent? Yes No NA
Feeds tolerated? Yes No Continue Beneprotein? Yes No NA
Bowel regimen? Yes No TPN
Lab results reviewed? Yes No Morning blood work? Yes No
LABS, TESTS Chest x-Ray tomorrow? Yes No
& PROCEDURES Other tests reviewed? Yes No Blood work for later today? Yes No
Blood consent on chart? Yes No Other procedures or tests: ___________________
Discontinue some medications
Allergies Reviewed Decrease some doses
No changes
MEDICATIONS Medications to be reassessed? Yes No Increase some medications
Can meds be changed to PO? Yes No Start new medications
Restart some held medications
Outdated medications for reorder? Yes No Change medications from: IV to PO PO to IV
Code status documented? Yes No
PSYCHOSOCIAL Status update: family called family present
Code status readdressed? Yes No
CONCERNS Family meeting planned? Yes No
Spiritual care/Social work/Ethics Yes No
RESEARCH STUDIES No Yes, Studies: ______________________________________________________________
Services to follow-up with today:
New physician consults? No Yes;
CONSULTATIONS
Surgery Nephro Resp Thoracics I.D. Other ____________________________
Allied health: Dietitian OT SLP APS Other ____________________________
ORDERS required? Yes No
READ-BACK of orders? Yes No
TRANSFER out of ICU? Yes No
OTHER FOLLOW-UP, PLANS or GOALS
OTHER GOALS