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BRAIN SHEET WITH SHIFT HOURSPt/DOB:
                                              MDs:
                               Armb...
BRAIN SHEET WITH SHIFT HOURS













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Nurse brain sheet_with_shift_hours

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Transcript of "Nurse brain sheet_with_shift_hours"

  1. 1. BRAIN SHEET WITH SHIFT HOURSPt/DOB:
 MDs:
 Armbands:



























DNR



























PMHx:
 Falls
 Allergy:___________________________

 ID
bands:
on,
Name/DOB
verified?

Skin:














WNL
 Chest
Tubes:



Rt/Lt/M‐S
 ROM:







WNL
 Neuro:












WNL
 GU:











WNL
Temp:
 #
of
tubes:
 Full
 Lethargic
Agitated
 Last
Void:
Moisture:
 Anterior/Posterior/Lateral
 Weakness:
 Disoriented
to:
 
Turgor:
 
 Lt/Rt
 


























1
2
3
 I&O
cath
Color:
 Crepitus:
 
 Non‐responsive
to:
 Foley
Bruises:
 To
Waterseal/Airleak
 Abnormal:
 Verbal/tactile/pain
 
Rashes/Redness:
 To
Suction:

 Contractures
 
 Urine:
Wound
Present?

 Drainage:
 Deficits
 Abnormal
Speech:
 
Other:
 
 
 
 Other:

 Dressing:
 Neuro√s
q____

 Last
changed?
Braden:
Wound
Care





(note
site,
type,
drains,
tx,
vac
settings)
 Gastrointestinal:
 Tubes:
 IV
Access:

 WNL
 NGT/OGT/Dobhoff
 PIV/SL
1
 Diet:
 Date
inserted:
 Location
 
 Lt/Rt
nare
 Gauge
 Aspiration
prec.
 Placement
 √’d
 Date
inserted
 Nausea/vomiting
 Gtube/Jtube/PEG
 IVF
 Diarrhea/constip.
 Clamped
 
 Abdomen:
 To
Suction:
 PIV/SL
2
 
 LIWS



LCWS
 Location
Respiratory:


WNL
 Cardiovascular:








WNL
 Bowel
Sounds:
 Drainage:
 Gauge
Respirations:
 JVD:
 Date
Inserted
 
 

 Abnormal
Pulse:
 Last
BM:
 Tube
Feed:
 IVF
Breath
Sounds:
 Edema:
pitting/non
 
 
 
LUL






















Rales
 
 Ostomy:
Lt/Rt
 Irrigation:
 PICC/CL/Port
LLL


















Rhonchi
 Calf
tenderness:
 Colo/Ileostomy
 
 SLC/DLC/TLC
RUL
















Crackles
 
 Stoma
 Residual:
 Power?
RML











Diminished
 Tele:
_________________
 Site:
 
 
RLL
 Peripheral
pulses
x
2/4/6
 Insertion
depth:
 
Bases
 
 Circumference:
Retractions/Grunting
 Cath
Lab?
 Dates:
Nasal
Flaring
 Angioseal?
Lt/rt
groin
 Inserted
 Dressing
changed
NPC/Prod
Cough?
 Stents?
 Daily
Review?

 Pacemaker:
A/V/AV/D
 IVF
O2______________
 AICD
 
RT
Q3/4/6/8H
CPT
 
 
Safety:
 ROM:
 Equipment:
 Today’s
Labs:
 Today’s
Tests:
Bed
low,
etc
 Nursing
Care:
 SCDs/CPM
 
Call
bell
in
reach
 
 Bed:

Atmos/Rental
Restraints:
 Isolation:
 

 
 Telemetry
1:1
Sitter
–
Suicide
 Activity:
assist/ad
lib
 Continuous
motion
Fall
precauitions?
 Bedrest/brp/chair/ambulate
 Continuous
pulse
ox
Seizure
precautions?
 Turns:
 BSC/Cane/Walker
ADLs:
 D/C
plan:
 
 FSBS





AC/HS

Q4H/Q6H/BID/___
Bath/Daily
care
 
 Turn
Q2H/Float
Heels
Incontinent

 Med
Rec
done?
Chart
Check?
 PT/OT/SLP
Eval/TX

 Wound
pictures?
Core
Meas?
 
Break/Lunch/Dinner
 Pneum/CHF/AMI/SCIP
Snack







Feeder
 
 

  2. 2. BRAIN SHEET WITH SHIFT HOURS













Time
 Med/VS/FSBS/Procedure/Turn/Off/assess
0700
 



0800
 



0900
 



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