NURSING BRAINSHEETS 33 Brainsheet Database 1.04 Nursing... · Welcome to the Nursing Brainsheet...

NURSING BRAINSHEETS33 Brainsheet Database

Welcome to the Nursing Brainsheet Database by NRSNG.com.

I remember how hard it was in nursing school and as a new nurse to find a brainsheet that“worked” for me. They all either didn’t have enough space for notes or too much or were missing that ONE thing I needed.

Eventually, after several months on the floor in the ICU I finally found a report sheet (brainsheet)method that worked for me.

I guess what I am trying to say is that I get it . . . there is no one size fits all brainsheet so guess what we did . . .

We went to the source!

We asked nurses and nursing students working in the ICU, ED, MedSurg, OB, Peds . . . anywhereto send us their brainsheet so we could create the end-all-be-all database of brainsheets.

The response was AMAZING.

We received over 100 example brainsheets.

This database includes the top 33. We will continue to grow the database as time goes on. You can see the most up to dateversion at NursingBrainSheets.com.

What is NRSNG?Glad you asked . . . it’s NURSING without the vowels . . . get it?

My experience with nursing education sucked (to put it gently).

So in 2014 I set out on a mission to change the way nursesare educated . . . and NRSNG.com was born.

We believe that through engaging students, providing support and basically giving a damn that nursing studentscan not only LEARN how to be a nurse, but enjoy it too.

The NRSNG family has now reached all 50 states and over185 countries from Afghanistan to Zimbabwe . . . literally.

So welcome aboard . . . we are glad to have you!

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HANDOFF AND REPORT SHEET

Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets

NAME AGE ALLERGIES CODE DX BACKGROUND PMH PSH

DOCTORS:

NEUROLOGICAL

Orientation

Pupils

Extremities

Follows Commands

Speech Clarity

Behavior

Sensation

Orientation

RESPIRATORY

O2 Delivery

Normal Stats

Lung Sounds

SKIN

Breakdown

Status of surgical sites

Dressings to change



HANDOFF AND REPORT SHEET


CARDIAC

Rhythm, Rate, Trends

BP Trends

Medication available for control

Pulse location, strength, cap refill

Edema

SCDs, TEDS, VTE Prophylaxis

Fluids/Drips

Temps

GASTROINTESTINAL

Diet/tolerance/residuals

BM date/pattern

Nausea/Vomiting

Blood sugars/type of insulin/SCIP?

GENITOURINARY

Method

Type, amount, color

Dialysis/Schedule

PAIN

Sources of pain

Pain control/last PRN meds

Pain levels

PLAN FOR PATIENT

Discharge plans

Upcomming procedures

PRN meds

Family dynamics



ULTIMATE CLINICAL BRAIN SHEET


REASON FOR HOSPITALIZATION:

FOCUSED ASSESSMENT:

CONSULTATION/TESTS:

ASSESSMENT NOTES:

PATIENT MEDICATIONS:

NAME REASON CONSIDERATIONS TIME




LAB VALUES

Na

K

Cl

CO2

BUN

Creat

pH

135-148

3.5-5.3

100-112

23-29

5.0 - 25.0

0.5 - 1.7

7.35-7.45

WBC

RBC male

RBC female

Hgb male

Hgb female

Hct male

Hct female

3.6-9.2

4.39-5.58

3.70-5.14

13.7-17.3

12-15.5

39-49

35-46

Platelet

Albumin

Ca

PT

aPTT

INR

Billirubin

140-400

3.5-5.0

8.3-10.3

10.4-12.2

24-33

2.0-3.0

0.0-1.0

ULTIMATE CLINICAL BRAIN SHEET

INTAKE & OUTPUT

IV SITE ASSESSMENT/FLUID/RATE

CALCULATIONS

THINGS TO RESEARCH/IMPROVE

PATIENT VITALS:

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

Time

Pulse

Pulse Ox

Respirations

BP

Temp

Pain

TASKS/NOTES



PATIENTS SIMPLE BRAINSHEET


Name: IV:

Tele:

Admin

DX:

Fluids:

BS:

Diet:Dr:

O2:HX:

Neuro:

Mobi:

GU:

Pain:

GI:

Skin:

Iso

CX

Res Res

C L D W

CP

E

T

T

T

Name: IV:

Tele:

Admin

DX:

Fluids:

BS:

Diet:Dr:

O2:HX:

Neuro:

Mobi:

GU:

Pain:

GI:

Skin:

Iso

CX

Res Res

C L D W

CP

E

T

T

T





Tests

IV

Tele Foley

FS

O2

Last Pain Med

Meds

Pain MedBM

PATIENT ID LABEL

Last FS

Tests

IV

Tele Foley

FS

O2

Last Pain Med

Meds

Pain MedBM

PATIENT ID LABEL

Last FS

Tests

IV

Tele Foley

FS

O2

Last Pain Med

Meds

Pain MedBM

PATIENT ID LABEL

Last FS

Tests

IV

Tele Foley

FS

O2

Last Pain Med

Meds

Pain MedBM

PATIENT ID LABEL

Last FS




VERTICAL PATIENTS BRAINSHEETS

Labs:

Pain:

Pt: Age: Rm#

RN:

Dx:

FSBS: Coverage:

T

O2

RR

B/P

/10/10

K-

Na-

PO IV

x0700

x0800

x0900

x1000x1100

x1200

x1300

IV

RATE

NOTES

Labs:

Pain:

Pt: Age: Rm#

RN:

Dx:

FSBS: Coverage:

T

O2

RR

B/P

/10/10

K-

Na-

PO IV

x0700

x0800

x0900

x1000x1100

x1200

x1300

IV

RATE

NOTES

Labs:

Pain:

Pt: Age: Rm#

RN:

Dx:

FSBS: Coverage:

T

O2

RR

B/P

/10/10

K-

Na-

PO IV

x0700

x0800

x0900

x1000x1100

x1200

x1300

IV

RATE

NOTES



FREEHAND BRAINSHEET


DX/Docs:

pH:

Neuro: Cardio:

Resp: GI:

GU: Skin:

Labs: Orders:

IV/ Lines: Meds:

Allergies:

Code Status:

Diet:

Precautions:

PMH: Activities/ Misc:

pCO2:pO2:HCO3:FiO2:

DX/Docs:

pH:

Neuro: Cardio:

Resp: GI:

GU: Skin:

Labs: Orders:

IV/ Lines: Meds:

Allergies:

Code Status:

Diet:

Precautions:


pCO2:pO2:HCO3:FiO2:

DX/Docs:

pH:

Neuro: Cardio:

Resp: GI:

GU: Skin:

Labs: Orders:

IV/ Lines: Meds:

Allergies:

Code Status:

Diet:

Precautions:


pCO2:pO2:HCO3:FiO2:

DX/Docs:

pH:

Neuro: Cardio:

Resp: GI:

GU: Skin:

Labs: Orders:

IV/ Lines: Meds:

Allergies:

Code Status:

Diet:

Precautions:


pCO2:pO2:HCO3:FiO2:

dyspnea

wheezes

Respiratory (Air): cough

rales

rhonchi color:

Cardiovascular (Water):Homan's Signdisphoresishematomashemorrhoids

breast engorgement orthostatic hypot'n petechieaedemavertigo

lochia: /°; color: ; odor: clots

GI (Food/Elim/Hazards): n/v constipation

bowel sounds x abd distention diarrhea flatus hemorrhoids last stool

appetite/intake:

abd tone:

GU (Elim/Hazards): with assist?bladder distentionoliguria

urine retention

dysuria

foley: Fr; @ mL

voiding pattern:

IV: @ cc/°; ; ;

MS (Activity/Normalcy):diastasus rectusuterine cramping

abdominal striae perineal muscles

fundal location: ; consistency:

mobility:

Integument (Hazards/Normalcy):soft firmdry intact

breasts: nipples: perineal: swelling bruising

laceration episiotomy

pigmentation: (nipples, linea negra, striae, chloasma)

REEDA

CNS (Social Interaction/Hazards): LOC tremors pain clonus

epidural @ DTR's

affect:

pumpingHealth Deviation:

postpartuminfant security teaching

Developmental / Emotional:need recv'dbreastfeeding consult?

neo. care (ch. 19) inquisitive?

bonding:

social support:

Sex: Apgar 1m: 5m: Blood Type: Wt. Len. Dir. Coombs:




POSTPARTUM BRAINSHEET

°




POSTPARTUM BRAINSHEET

Student: Client Initials:

Date: Room:

Diet: Nurse:

Allergies:

Cultural Background:

Primary Language:

Date & Time of Birth:

Childbirth Prep?

Hct: Hgb: Blood Type:

T P A L Rhogam: Needed Given

Vaginal Cesarean Rubella: Imm Non-imm

Feed: Breast Bottle HBSAg: Pos Neg

Med Order Last Given

1500–1600: charts; assess

1600–1700: chart vs;

1700–1800:

1800–1900:

1900–2000:

2000–2100:

2100–2130: final charting;

Input: Vitals

Temp

HR

Output: RR

Pain

BP




PATIENT MEDSURG BRAINSHEET Date: 7 8 9 10 11 12 1 2 3 4 5 6 7

Room: Name: Age: Dx: Hx:

O2: S/L: IV: Tele: Diet: Amb:

T:

P: R: B/P: O2: T:P: R: B/P: O2: T:P: R: B/P: O2:Accu : 07 1100 1700 2100

Assessment

7 8 9 10 11 12 1 2 3 4 5 6 7



T:


Assessment

7 8 9 10 11 12 1 2 3 4 5 6 7



T:


Assessment

Hgb

HctWBC Plt

Na

K+

Cl

CO2

BUN

Cr Ca

Mg

PO4PTT PT INRGlu




POSTPARTUM MOM-BABY BRAINSHEET

NAME

TIME OF DELIVERY

V C EPISIOTOMY: Y / N

COMPLICATIONS

G P

ALLERGIES

BLOOD: A O B AB + -

NEED RHOGAM: Y / N

RUBELLA: IMM / NON

HEP B: POS / NEG

HIV: POS / NEG

NOTES

MEDS:

VOIDING: Y / N IN

PASSING GAS: Y / N OUT

DIET

BABY

PEDIATRICIAN

MALE FEMALE

WT: LBS OZ GRAMS

APGARS: 1MIN 5MIN

GESTATION: WKS DAYS

BREAST / BOTTLE / BOTH

FEEDING? Y / N

LACTATION CONSULT: Y / N

PEE: Y / N POOP: Y / N

HEP B: Y / N

HEARING TEST: Y/ N

BLOOD: A O B AB + -

COOMBS: NEG / POS

PKU: Y / N

LABS

MEDS

VS 0800 1200 1600

T

RR

VS 0800 1200 1600

T

BP

RR

O2

PAIN

B U B B L E H E

1200

0800

1600




ICU DETAILED BRAINSHEET

Rm: Name: Resp: GI: Orders: RBC: Hgb: Hct:

POD: Age: Weight: Height:

RR: Pulse:

O2: Sputum:

BM: NG/OG/PEG: TF/DIET:

WBC: -Plt:

HX: Admit: Cardiac: Skin/Circ: BUN:

Creat:

GFR:

BNP: M.D's:

SCD'S: TEDS:

Intervention: NA:

K:

Cl: HR: BP: Tele:

GU: CO2:

ALB:

ALT:DX: Neuro: AST:

BILI: Ca:

Temp:

Urine:

Foley:

Voids:

Inc/Drsg: I. Ca: PROT:

Allergies: Chems q.: 7- 11- 16- Braces: TROP: CK-MB:

Lines/gtts: Meds: Pain: Mg:

Phos:

DIG: CT: PT:

INR:

PTT:CVL: -- Art Line:

CXR: UA:

COLOR:

CLAR:

GLUC:

KEY: Ppeak: Pmean: PEEP: I:E SPGR:

BLOOD:

PH:

PROT: FTOT: VTE: VETOT: ET SIZE:

* -LENGTH: -@ LIPS:

LIPID:

CHOL: HDL:

LDL:

TRIG:

CHARGE NURSE BRAINSHEET




Name:

Age

Diagnosis:

ADM Date

History

Allergy

Code

Isolation

FULL DNR NONE CONTACT DROPLET AIRBORNE PREVENTION

ROOM #:

Neuro

Cardiac/Drips

IV Access PIV X CL PICC HEMACATH A-LINE 02- BIPAP VENT:

RESP RA NC FM

AC Bilevel CPAP

ABG:

Settings:

GI OG/NG/PEG NPO DIET

GU VOIDFOLEY

ANURIC

Labs FS q Lyte Prot

Skin Pressure Ulcer

DVT/PUD(circle)

Heparin/Arixtra/LovenoxTEDS/SCDSProtonix/Pepcid

SpokesmanName

ABX

Daily Goals 1.2.3.4.


ROOM #:

PIV X CL PICC HEMACATH A-LINE 02- BIPAP VENT:

RA NC FM

AC Bilevel CPAP

ABG:

Settings:

OG/NG/PEG NPO DIET

VOIDFOLEY

ANURIC

FS q Lyte Prot

Pressure Ulcer


1.2.3.4.


ROOM #:


RA NC FM

AC Bilevel CPAP

ABG:

Settings:

OG/NG/PEG NPO DIET

VOIDFOLEY

ANURIC

FS q Lyte Prot

Pressure Ulcer


1.2.3.4.


ROOM #:


RA NC FM

AC Bilevel CPAP

ABG:

Settings:

OG/NG/PEG NPO DIET

VOIDFOLEY

ANURIC

FS q Lyte Prot

Pressure Ulcer


1.2.3.4.

5 PATIENT VERTICAL BRAINSHEET




Room Isolation

Patient

Diagnosis

Allergies

Code / Box / Rhythm

LOC / Activity / Fall Level

O2 / Breath Sounds

IV Site / Fluid / Rate

Diet / Accuchek

GI / GU

Skin / Pressure Ulcer Risk

Abnormal Labs

Med-Pass

PRN Meds

Consults / Tests / Surgery

To Do / Collect

Notes

MD

Room Isolation

Patient

Diagnosis

Allergies

Code / Box / Rhythm


O2 / Breath Sounds


Diet / Accuchek

GI / GU


Abnormal Labs

Med-Pass

PRN Meds


To Do / Collect

Notes

MD

Room Isolation

Patient

Diagnosis

Allergies

Code / Box / Rhythm


O2 / Breath Sounds


Diet / Accuchek

GI / GU


Abnormal Labs

Med-Pass

PRN Meds


To Do / Collect

Notes

MD

Room Isolation

Patient

Diagnosis

Allergies

Code / Box / Rhythm


O2 / Breath Sounds


Diet / Accuchek

GI / GU


Abnormal Labs

Med-Pass

PRN Meds


To Do / Collect

Notes

MD

Room Isolation

Patient

Diagnosis

Allergies

Code / Box / Rhythm


O2 / Breath Sounds


Diet / Accuchek

GI / GU


Abnormal Labs

Med-Pass

PRN Meds


To Do / Collect

Notes

MD




ICU BODY SYSTEM REPORT BRAINSHEETCODE STATUS ISOLATION ALLERGIES

PRECAUTIONS MD

DX NEURO WNL

sedated paralyzed icp drains NIHSS

LABS heparin drip 3% nacl drip

CULTURES

SERIAL LABS

ELECTROLYTE PROTOCOLK Mg

Ca Phos

CARDIO WNL

pacer / aicd ivc stents prn >

PULMO WNL VENT

ett trach weaning chest tubes

GI WNLNPOTF

BS: LBM: TFR:

ng og peg colostomy drains SLP

IMAGING

ENDO WNL

Accuchek Qinsulin drip glucommander lantus / 70/30

IV ACCESS PIV PICC CVC HD

DRIPS:

dsg change: tpa

limb alert

RENAL WNL

DIALYSIS d/c foley

PAST MEDICAL HISTORY

FAMILY / POA / ADVANCE DIRECTIVES YES ORTHO / MOBILITY WNL

Device: PT/OT

PROPHYLAXIS

pepcid protonix

lovenox heparin scds other:

NOTES SKIN / LDAs PRN MEDS

TEMP:

UO: UO:

TEMP:

UO: UO:

TEMP:

UO: UO:




PATIENT VERTICAL BRAINSHEET

Rm: Code: Age: Rm: Code: Age: Rm: Code: Age:

Name: Name: Name:

Dr: Dr: Dr:

Dx: Dx: Dx:

Hx: Hx: Hx:

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

I ________ I ________ O ________ O ________ IV ________ IV ________

I ________ I ________ O ________ O ________ IV ________ IV ________

I ________ I ________ O ________ O ________ IV ________ IV ________

Lungs: 02: Lungs: 02: Lungs: 02:

Heart: R: Heart: R: Heart: R:

Edema: Edema: Edema:

GI: LBM: GI: LBM: GI: LBM:

GU: GU: GU:

Skin: Skin: Skin:

Pain: Pain: Pain:

IV: IV: IV:

Diet: Diet: Diet:

Act: Act: Act:

Labs: Labs: Labs:

Rm: Code: Age: Rm: Code: Age: Rm: Code: Age:

Name: Name: Name:

Dr: Dr: Dr:

Dx: Dx: Dx:

Hx: Hx: Hx:

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

VS: Wt: ______ BS: 20 ________________ 21 ______ 24 ________________ 06 ______ 04 ________________

I ________ I ________ O ________ O ________ IV ________ IV ________

I ________ I ________ O ________ O ________ IV ________ IV ________

I ________ I ________ O ________ O ________ IV ________ IV ________

Lungs: 02: Lungs: 02: Lungs: 02:

Heart: R: Heart: R: Heart: R:

Edema: Edema: Edema:

GI: LBM: GI: LBM: GI: LBM:

GU: GU: GU:

Skin: Skin: Skin:

Pain: Pain: Pain:

IV: IV: IV:

Diet: Diet: Diet:

Act: Act: Act:

Labs: Labs: Labs:




PATIENT DETAILED BRAINSHEET

Dx PMH

Neuro AOX 3 2 1 Confused Forgetful Cards SR ST SB AF FL EF Venodynes

Resp LPM NC RA GI Incont Guiaic

GU Foley Voiding Incont Skin/Wound

Routine VS q4 ° Daily Wgt Strict I/O Labs BNP

CK

Trop

Cath/EP Lab

Fent Versed Cont

IV SL gtts

Plans Call MD

HR < >

SBP< >

DBP> T> RR

< > O2 < PTT >

R∆ Fall

Activity Precaution Diet

Name & Age Code Allergy NKDA MD

R1

N

CC

I/O

LC# DX Rm

NPO HH 2gNA ADA Renal Regularad lib BR x ° BRP AMB OOB to Chair c Assist x

Meds

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 FS

8 12 17 18 22

Ca

Mag

PhoPT/INR PTT

Full DNR/I

T BP

HR O2

R LS

Fall Bleed Cont Air Drop

IVF

ASP

ICU REPORT BRAINSHEET




CODE STATUS ISOLATION ALLERGIES

PRECAUTIONS MD

DX NEURO WNL

sedated paralyzed icp drains NIHSS

LABS heparin drip 3% nacl drip

CULTURES

SERIAL LABS

ELECTROLYTE PROTOCOLK Mg Ca Phos

CARDIO

pacer / aicd ivc stents prn >

PULMO WNL VENT

ett trach weaning chest tubes

GINPOTF

BS: LBM: TFR: ng og peg colostomy drains SLP

IMAGING

ENDO

Accuchek Qinsulin drip glucommander lantus / 70/30

IV ACCESS PIV PICC CVC HD

DRIPS:

dsg change: tpa limb alert

RENAL

DIALYSIS d/c foley

PAST MEDICAL HISTORY

FAMILY / POA / ADVANCE DIRECTIVES YES ORTHO / MOBILITY

Device: PT/ OT

PROPHYLAXIS

pepcid protonix

lovenox heparin scds other:

NOTES SKIN / LDAs PRN MEDS

TEMP:

UO: UO:

TEMP:

UO: UO:

TEMP:

UO: UO:

WNL

WNL

WNL

WNL

WNL

BOX BRAINSHEET




Room # Pt. Name: Age:

Sex:

EMV:

Service:

Attending:

Allergies:

ISO:

Diet:

IV: Fluids/Drips:

Admit Date & Diagnosis:

Procedures:

PMH:

Password:

Output: Activity: O2: VS:

Telemetry:

Skin: To Do:

Pump/ Drain Totals:

FS:

Meds:

8

12

17

21




HOURLY BRAINSHEET

Neuro : Resp :

- activity BS: WOB: aeration:

- pupils

- pain rate: sats: O2:

tx: CV : access:- temp GI/GU :- HR - feeding tube

- BP - abdomen

- p/p - urine

- stool

Skin : Social & Teaching :

quad conex allergies IPOC ER equipment monitors ID Kardex board tubing uids bath linens

wt: vs: iso:

allergies: admit:

History

08/20 09/21 10/22 11/23 12/00 13/01

14/02 15/03 16/04 17/05 18/06 19/07




PATIENT ID LABEL

CARDIAC BRAINSHEET

Hgb

HctWBC Plt

Na

K+

Cl

CO2

BUN

Cr Ca

Mg

PO4Glu

Room: Allergies:Age: D.C:

Dx:Tx:

PMHx:

ADT:

Diet: Post-Op day: Pre/Post W:

MM/DD/YYYY GU: Mobility: ISO:

SED0H:

Meds (check the box)0700 | 15/3

0800 | 16/4

0900 | 17/5

1000 | 18/6

Meds1100 | 19/7

1200 | 20/8

13/1 | 21/9

14/2 | 22/10

PNR Meds:Ca

PO4

TPBCL AM

PM

12

7

Assess:

1. Safety

Bed low

Bed rail

Call bell

Allergy/ID

Suction/ O2

2. LOC

O/Ax3

GCS

PEERLA

L

R

3. Check

Chest Pain

Dizziness

Turgor

Skin Color/ T0

Cough

SOB

Radial Pulse

Pedal Pulse

4. Auscultation

APE to Mam. Apical HR

Lungs

BS x 4

BM (last)

Flatus

Tele/Rhythm

IV

Re-site

Tubing

Bag

Incision

Dressing :

Site

EdemaL

R

Notes:




CARDIAC BRAINSHEET

Time

BP

HR

SpO2

Temp

RR

Pain

I/O %Eaten: Fluid Restriction: (ml)

D: U/BM/Y/BL Time (ml) Color/Odor/Type I: (What) Time (ml)

Orders:SBAR Report

1. All meals sign off

2. Three flowsheets done

Report:

Room#/Name

Chief Complaint Lab work Imaging Medications Abnormal Results

Done Needs XR-

CT-

US-

Given:

Redraws: Needs:

Done Needs XR-

CT-

US-

Given:

Redraws: Needs:

Done Needs XR-

CT-

US-

Given:

Redraws: Needs:

Done Needs XR-

CT-

US-

Given:

Redraws: Needs:

Done Needs XR-

CT-

US-

Given:

Redraws: Needs:

ED BRAINSHEETS







PATIENT ID LABEL

ROUNDS BRAINSHEET

Room: Date:

Chief Complaint:

Diagnosis:

Code Status:

PMH:

MD:

Level of Care:

Allergies:

Precautions:

Lab Results:

Test Results:

VS: MJ:

Neuro:

Cardiac:

Resp:

GI:

GU:

Skin:

Safety/Mobility:

Pain:

Required For Daily Health Care Team Rounds

Case management reports, Dx, OBS, GMLOS, RightCare

From: Home/SNF

Telemetry: Y/N Rhythm: Respiratory:

O2 Needs: Chronic: Y/N

IV/access: IV meds:

Activity:

Diet:

Restraints: Y/N

Tolerating: Y/N

PT Eval: Y/N

VTE proph: Mech/Chem/Amb 3x per day

Last BM: Foley: Y/N

Chronic: Y/N

Barriers to Transitioning to Next Level of Care? Anticipated Transition Date?




DETAILED BODY SYSTEM BRAINSHEET

PATIENT ID LABEL

Room #: Level of Care: PCU/5B/ICU

Dx/Scenario:

PMHx:

24 Hour Events Doctors/Consults

RT#

Code:

ISOL:

Allergy:

Social/Family: Last updated:

POA:

NEURO: Fall Risk: CAM-ICU: MAAS:

A/OX:

Pain:

Y/N

SAT

Y/N

+/-

CARDIAC:Rhythm/HR:

BP:

Qtc:

T max: EF:

PIV CL PICC

ART

Gtts:

PULM: ABG SBT Ventilator BipappH

PCO2

PO2

HCO3

Y/N

Pass/Fail

MODE:

VT:

FiO2:

PEEP:

PS:

MODE:

FiO2:

PS:

Rounds Sequence

1. Description of Patient

2. Sig. Events of last 24 hrs.

3. Vital Signs/

4. DVT Prophylaxis

5. Oxygen Status

6. Lines

7. Mas/Sed gtts/CAM-ICU

8. Skin/Surgical Wounds

9. Mobility Status

10. Nutrition

11. Concerns/Request

12. Safety Risk(s)

High risk med/safety

ID Band CheckAlarm Limit Checks

Bedside Assessment

Needed?

Any Questions?

18*06

19*07

POC:GI:

GU:

SKIN:

ABS/TESTS:

BS:

Diet/TF: Last BM:

I/O:

24 hr UO:

Wounds:

Wound Consult: Y/N

Repeat Labs:

PT

PTT

INRWBC

Hg

HctPlt

Na

K

Cl

CO2

Ica

Mg

Phos

BUN/Cr glucose

07*19

08*20

09*21

10*22

11*23

12*00

13*01

14*02

15*03

16*04

17*05

4 PATIENT OB BRAINSHEETS




Baby Education Care Plan

Boy Girl Name Breast Bottle

Dr. GA Weight

AGA SGA LGA BGMs until NICU

Blood type 24 Hr VS/CCHD/PKU due @

Bath Given Circumcision TCI @ hrs.

Vitals

Time Temp HR RR

Time Temp HR RR

Additional Info:

Time Feed Void Stool

Mom Education Care Plan

Room Name Day

Dr. G P Age

Date & Time of Delivery F/C DTV

Ante Vag CS PPS Epis/Lac ° Anesthesia

Blood type Rubella GBS HepB HIV

Flu Tdap Married FOB 1900 2300 0300

Allergies:

Hx:

Pain Meds: Anaprox Motrin @

Percocet @

Scheduled Meds:

Baby Education Care Plan

Boy Girl Name Breast Bottle

Dr. GA Weight

AGA SGA LGA BGMs until NICU

Blood type 24 Hr VS/CCHD/PKU due @

Bath Given Circumcision TCI @ hrs.

Vitals

Time Temp HR RR

Time Temp HR RR

Additional Info:

Time Feed Void Stool

Mom Education Care Plan

Room Name Day

Dr. G P Age

Date & Time of Delivery F/C DTV

Ante Vag CS PPS Epis/Lac ° Anesthesia

Blood type Rubella GBS HepB HIV

Flu Tdap Married FOB 1900 2300 0300

Allergies:

Hx:

Pain Meds: Anaprox Motrin @

Percocet @

Scheduled Meds:

NEURO ICU BRAINSHEET




PACU:Intake

PATIENT ID LABEL OutputEBLDrains Output

NEURO DEFICITS

DRAINS

Type:

Level:

24 hr Output:

Drainage:

CSF Studies:

CVRhythm:

BP Limits:

CPV Limits:

IVF/Drips

Central Line: Y/NLocation:Change date:

Peripheral IV: Y/NSite/Gauge/Date Inserted:

PULMONARY

Breath Sounds:

O2 Therapy:

Tracheostomy: Y/N size:

Ventilator: Y/NSettings:Secretions:

RR:

O2 Stats:

GI Diet:Swallow Eval?

Tube Feeds: Y/N

Type/Rate:

Dobhoff or PEG

Location:

Size and Markings:

GU

Voids: Y/N

Catheter Type:Leg Strap on: Y/N

Last BM:

SKIN/ACTIVITY/RESTRICTIONS PRN MEDS LABS

TO DO ASK MD

PT/OT/Speech/MSW

Restraint Type:

Due:

19:

20:

21:

22:

23:

24:

01:

02:

03:

04:

05:

06:

07:

Accuchecks: AC/HS Q6H gtt

-Max: TED/SCDs

ICU BRAINSHEET




Room: DATE:Patient Age Sex Admitted: HD: LOS: Diagnosis: ProcedureComorbid Conditions\Hx: Code Status: Allergies

SIGNIFICAT HOSPITAL HISTORY BODY SYSTEMS

Neuro: Orientation: Psych/Soc Pupils: Extremity Strength Temp: Activity Weight: Fall Precaution: Restraints

Neuro: PLAN: VARIANCE

CV: Rhythm: HR: BP: “A” Line Swan Ganz: PA PAWP CVP: CO Pacer Wires: K+: CPK: CBC: Hct: PT Mg+: MB’s: Trop: HGB PTT Ca: Edema (small= +1 moderate=+2 Pitting= +3) Pulses (R) (L) (absent=0 weak=1 strong=2) PICC/Central line/ IJ: Hep Lock:

DRIPS: cc/hr

Cardiovascular: PLAN: VARIANCE

PUL: Extub: RR: O2 BS: Mask: Coughing Sputum Tri ow Chest Tubes: Bipap: ABG: Mode: Cu Pressure FiO2 TV rate

Respiratory PLAN: VARIANCE

GI Abd Contour BS Flatus: NG pH: Diet: BM Feeding Appetite: Chemstrip:

GI: PLAN: VARIANCE

GU Foley: Cath Care: SG PD Urine Output: Hemo

GU: PLAN: VARIANCE I&O’s

Skin/dressing/incisions:

Braden Scale:

Specimens:

Test, Labs

Procedures, hx, preps

Other: Other:

Discharge Plan:

Variance to Discharge Plan: Barrier

Resolution:

Consults:

Teaching/learning:

Consults:

Special Needs:

Ca

Mg

PTT

PT

CPK

CKMB

CKMB%

TROP

BOXES BRAINSHEET




Name: MD: Age: Room: Code Status:

Diagnostic Symptoms Personal Family Activity Vent

Neuro Cardio Resp History

Skin Urinary GI

Nutrition Labs Na CL BUN K CO2 CR

Wbc hgb plts Hct

IV Education

Tests POC Meds Core Measures/VTE

1800 2200 0200

1900

V/S:

2300

V/S:

0300

V/S:

2000 0000 0400

2100 0100 0500 In Out

BOXES BRAINSHEET




SIMPLIFIED BRAINSHEET




N:

CV:

R:

GI:

GU:

Sk:

IV:

Pain:

VS:

Accu:

I: O:

Labs:

To Do:

Labs needed:

Dx:

Cons:

Plan:

Report:

Dem:All:Adm, c/c:PMHx:

Plan:

Systems:

IV:Rx:Labs:Pending:Issues:

WHITESPACE BRAINSHEET




Rm: Name: CODE: DONE:

In Out VS

Med

Mar

IV

Post

Pt.

Strip

Labs Tape

IV Fluids Re-check

NaCl

Hep

NTG

Protocols Time Value Replace Re-check MAR Times Glucs

K+ 0700

Mg 1200

Heparin 1700

NOC

MEDSURG BRAINSHEET




RM# PT: age: M / F Code:

Diet:

HX

Allergies:

Neuro AOX 1 2 3 Confused Forgetful Skin/Wound

GI Incont UG Foley Voiding Incont

I/O Activity

VS

T BP

HR O2

R

Resp

Meds Labs

Precautions : contact / fall /

aspiration (HOB °) / neuro

IV/Lines

Diabetic Mgmt

Insulin

accu

SS

Consult/Appts

DX:

seizure /

PATIENT CIRCLE BRAINSHEET




RM# PT: age: M / F Dr.

DX: diet: d/weight

Allergies:

O2 : nebs activity: ad lib / bed rest / in chair / PT / walker / assist x

IV fluids: access: PCA (dem / morph)

DNR pain meds (last dose?):

voids: BRP / foley / BSC / urinal / diaper SNF / rehab consult (need / done)

UA / C&S (need / done) stool x for guiac / c-diff / WBC

precautions: contact / fall / seizure / aspiration (HOB °) / neuro

FSBS: ac&hs / q hrs / SS: regular insulin / Novolog

2100: 0730: 1130: 1630:

labs: CBC / MP / CE / BNP / Mag / Phos / K / Lytes / H&H / PT/INR / PTT /

CXR / EKG / Echo / MRI / US / CT permit? Y / N list? Y / N

VS 0600 T P R BP O 2

T P R BP O2

Notes:

Hx :

Labs:

Na:

K:

BUN:

Creat:

WBC:

H/H:

Plat:

SBAR BRAINSHEET




SPatient name Age

Room number Admit date

1 Dx 2 Dx

C/O

allergies Physician

Attending

Consultants

Pgr/#

Code status

Advanced directive on chart?

BHistory

Surgery: Surgeon

Anesthesia Anesthesiologist EBL

Isolation Core Measures

Restraints CHF MI PNA

Fall risk Vaccine- PNA Flu

ACardiac: BP/HR/Peripheral pulses/Edema/Heart sounds

Current rhythm

Daily wt?

DVT prophylaxis

Pain/sedation

Pain scale

Location

Meds type and last dose

Pulmonary: Breath sounds/Secretions/ SpO2/UPAs/PIP/ Spontaneous VT & VE

Vent/bipap etc

settings

Accu checks A1C

Frequency

Last Results

GI NG/OGT

BS Last BMDiet GI Prophylaxis

Skin Wounds/Drainage

Staples Drains

Location

Ducub photo on admission

GU Foley/void

Output

IV Date inserted

Fluids Gtts

Psych Social

Meds Pending orders

Na Cl Bun gluc mg BNP Coags

INR

PTT

Next lab

Hct

W Pl

Hgb

UA CT

CXR

MRI

Echo

K Co Cr Ca Phos DDimer Cultures

Cardiac enz 1 2 3

RDC Plan. Is pt informed of plan 24 hour orders reviewed Shift goals

MEDS-LABS-VITALS BRAINSHEET




Date: Phone# Charted ? Voice Care?

Room # Name: Age: Code Status:

DR: DX: Allergies:

Diet: Activity: 02: HT/WT: IV:

MEDS: 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 00 01 02 03 04 05 06

TIME: T P R BP POX

TIME: T P R BP POX

TIME: T P R BP POX

Glucometer: Break: Lunch: Dinner: H.S.:

IN: OUT: Monitor Reports: 7-3

3-11

11-7

HX REPORT A&O____ Confused AP Reg Irreg Lungs: clear decreased rhonchi insp exspir wheezes abd soft nontender distended BSX4 hyper hypo +PP edema - 0 1 2 3 4 LE UE Pain Foley

Plans for the Shift:

ASSESS A&O Confused AP Reg Irreg Lungs: clear decreased rhonchi insp exspir wheezes abd soft nontender distended BSX4 hyper hypo +PP edema - 0 1 2 3 4 LE UE Pain Foley

Yesterday Today RBC (4.2-5.4) WBC (4.8-10.8) HGB (M14-18)(F12-16)

HCT (M42-52)(F37-47)

PLTS (150-400) PT (9.3-11.8) INR (0.0-3.5) PTT (23-33.4) BUN (M9-21)(F7-18)

CREAT (M0.8-1.2)(F.7-1.2)

Na+ (135-145) K+ (3.5-5.5) Mag+ (1.8-2.4) Ca++ (8.5-10.5) DIG (0.9-2.0) BNP (0-100) Troponin

Enzymes: + - 1 2 3

TESTS/RESULTS

NEW ORDERS

ICU BOX BRAINSHEET




NAME

DOB Rm# Admit Date

Wt: CODE: PMD:

Consults:

1900

_____________________ 2000

_____________________ 2100

_____________________ 2200

_____________________ 2300

_____________________ 0000

_____________________ 0100

_____________________ 0200

_____________________ 0300

_____________________ 0400

_____________________ 0500

_____________________ 0600

_____________________ 0700

ISO:

ALLERGIES

Diagnosis Medical Hx Procedure/Surgery

POD#

Diet BP LABS

P

IV RR

T

SpO2

NEURO RESP O2: Tx: Vent Settings:

CARDIAC Tele/Rhythm Pacemaker

SKIN GI/GU MUSC Activity

Orders/Plan:

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