Nurse Brain Sheet New Shift Report PDF

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Summary

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Description

BRAIN SHEET – NEW SHIFT REPORT Room:____________ DATE:____________ Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______ Diagnosis:__________________________Procedure___________________________________ Comorbid Cond itions\Hx:_____________ Code Status:______Allergies___ _________________ ______________________________________________________________________________ SIGNIFICANT HOSPITAL HISTORY

BODY SYSTEMS Neuro:

Neuro: Orientation:

VARIANCE

Pupils: Temp: Weight: Restraints

Psych/Soc

Extremity Strength Activity Fall Precaution: 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:

PUL:

PLAN:

Cardiovascular:

PLAN:

VARIANCE

cc/hr

Extub:

BS: Coughing Chest Tubes: ABG:

GI BS NG Diet: Feeding Chemstrip: GU Foley: Urine Output:

RR:

O2

Sputum Bipap: Mode: FiO2 TV rate Abd Contour Flatus: pH: BM Appetite: Cath Care: PD Hemo

Skin/dressing/incisions: Braden Scale: Other: Discharge Plan:

SG

Respiratory

PLAN:

VARIANCE

GI:

PLAN:

VARIANCE

Mask: Triflow Cuff Pressure

GU: I&O’s

PLAN:

VARIANCE

Specimens: Test, Labs Procedures, hx, preps Other: Teaching/Learning: Consults:

Variance to Discharge Plan: Barrier Resolution: Consults:

Special Needs:

Ca Mg

PTT PT

CPK CKMB

CKMB% TROP...