Documenting an intensive care round
Daily notes by system, step-down letters to the admitting team and family meeting notes.
The morning round, system by system
Day four after a Hartmann's procedure for perforated diverticulitis.
Day four post Hartmann's for perforated sigmoid diverticulitis.
Neuro, off sedation since yesterday, RASS 0, CAM-ICU negative. Paracetamol and fentanyl PCA.
CVS, noradrenaline off at 0200, MAP 74, lactate 1.1.
Resp, extubated yesterday, high flow 40 litres at 35%, sats 96, rate 18.
Renal, urine output 0.8 mL per kilo per hour, creatinine 138 from a peak of 212.
Gut, stoma pink, not working yet, NG 250 mL. ID, peritoneal fluid grew E. coli sensitive to ceftriaxone. Change pip-taz to ceftriaxone and metronidazole, stop after day five from source control.
Out the arterial line. Step down to the ward tomorrow if stable.
Neuro
Sedation off. RASS 0, CAM-ICU negative. Paracetamol, fentanyl PCA.
Cardiovascular
Noradrenaline ceased 02:00. MAP 74. Lactate 1.1.
Respiratory
Extubated day 3. HFNP 40 L/min, FiO2 0.35. SpO2 96%, RR 18.
Renal
UO 0.8 mL/kg/h. Cr 138 (peak 212).
GI
Stoma pink, not yet functioning. NG output 250 mL.
ID
Peritoneal fluid: E. coli, ceftriaxone sensitive. Piperacillin-tazobactam changed to ceftriaxone and metronidazole; cease after day 5 from source control.
Plan
- Remove arterial line
- Step down to ward tomorrow if stable
When the patient leaves the unit
- Step-down letter
- To the surgical team: the ICU course by system, lines in place, the antibiotic stop date and what to watch for.
- Family meeting note
- Who was present, what was explained, the questions asked and the goals agreed.
