Nurse brain sheet_new_shift_report

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Nurse brain sheet_new_shift_report

  1. 1. BRAIN SHEET – NEW SHIFT REPORTRoom:____________ DATE:____________Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______Diagnosis:__________________________Procedure___________________________________Comorbid ConditionsHx:_____________ Code Status:______Allergies__________________________________________________________________________________________________SIGNIFICANT HOSPITAL HISTORY BODY SYSTEMSNeuro: Neuro: PLAN: VARIANCEOrientation:Psych/Soc Pupils:Extremity Strength Temp:Activity Weight:Fall Precaution: RestraintsCV: Cardiovascular: PLAN: VARIANCERhythm: HR:BP:“A” LineSwan Ganz: PA PAWPCVP: COPacer Wires:K+: CPK: CBC: Hct: PTMg+: MB’s: Trop: HGB PTTCa:Edema (small= +1 moderate=+2 Pitting= +3)Pulses (R) (L) (absent=0 weak=1 strong=2)PICC/Central line/ IJ:Hep Lock:DRIPS: cc/hrPUL: Extub: RR: O2 Respiratory PLAN: VARIANCEBS: Mask:Coughing Sputum TriflowChest Tubes: Bipap:ABG: Mode: Cuff Pressure FiO2 TV rateGI Abd Contour GI: PLAN: VARIANCEBS Flatus:NG pH:Diet: BMFeeding Appetite:Chemstrip:GU Foley: Cath Care: SG GU: PLAN: VARIANCE PD I&O’sUrine Output: HemoSkin/dressing/incisions: Specimens: Test, LabsBraden Scale: Procedures, hx, prepsOther: Other:Discharge Plan: Teaching/Learning: Consults:Variance to Discharge Plan: BarrierResolution: Special Needs:Consults: Ca PTT CPK CKMB% Mg PT CKMB TROP

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