Nursing Brainsheet Database - For RNs PDF

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Summary

The documents are to help the nursing student with EKG interpretation. There are also study guides to help with med surg and of course the nclex....

Description

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 . . . anywhere to 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 date version 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 nurses are educated . . . and NRSNG.com was born. We believe that through engaging students, providing support and basically giving a damn that nursing students can not only LEARN how to be a nurse, but enjoy it too. The NRSNG family has now reached all 50 states and over 185 countries from Afghanistan to Zimbabwe . . . literally. So welcome aboard . . . we are glad to have you! Happy Nursing! -Jon Haws RN BSN CCRN CEO/Founder NRSNG.com p.s. Join us on social media and say “HI” (FB, IG, Snapchat, Twitter, YouTube, Pinterest . . . you get the idea).

HANDOFF AND REPORT SHEET 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

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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

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ULTIMATE CLINICAL BRAIN SHEET REASON FOR HOSPITALIZATION:

FOCUSED ASSESSMENT:

ASSESSMENT NOTES:

CONSULTATION/TESTS:

PATIENT MEDICATIONS:

NAME

REASON

CONSIDERATIONS

TIME

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ULTIMATE CLINICAL BRAIN SHEET INTAKE & OUTPUT

LAB VALUES Na

135-148

WBC

3.6-9.2

Platelet

140-400

K

3.5-5.3

RBC male

4.39-5.58

Albumin

3.5-5.0

Cl

100-112

RBC female

3.70-5.14

Ca

8.3-10.3

CO2

23-29

Hgb male

13.7-17.3

PT

10.4-12.2

BUN

5.0 - 25.0

Hgb female

12-15.5

aPTT

24-33

Creat

0.5 - 1.7

Hct male

39-49

INR

2.0-3.0

pH

7.35-7.45

Hct female

35-46

Billirubin

0.0-1.0

PATIENT VITALS: Time

Time

Time

Pulse

Pulse

Pulse

Pulse Ox

Pulse Ox

Pulse Ox

Respirations

Respirations

Respirations

BP

BP

BP

Temp

Temp

Temp

Pain

Pain

Pain

Time

Time

Time

Pulse

Pulse

Pulse

Pulse Ox

Pulse Ox

Pulse Ox

Respirations

Respirations

Respirations

BP

BP

BP

Temp

Temp

Temp

Pain

Pain

Pain

IV SITE ASSESSMENT/ FLUID/RATE

CALCULATIONS

TASKS/NOTES

THINGS TO RESEARCH/ IMPROVE

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PATIENTS SIMPLE BRAINSHEET Name:

CX

IV: Tele:

Admin

Fluids:

DX: BS: Res

Dr:

Diet:

HX:

O2:

C

Neuro:

CP

Mobi:

E

L

Res D

W

GU: GI: T

Skin: Pain:

T Iso T

Name:

CX

IV: Tele:

Admin

Fluids:

DX: BS: Res

Dr:

Diet:

HX:

O2:

C

Neuro:

CP

Mobi:

E

L

Res D

W

GU: GI: Skin:

T

Pain: T Iso T

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PATIENTS SIMPLE BRAINSHEET Name:

CX

IV: Tele:

Admin

Fluids:

DX: BS: Res

Dr:

Diet:

HX:

O2:

C

Neuro:

CP

Mobi:

E

L

Res D

W

GU: GI: T

Skin: Pain:

T Iso T

Name:

CX

IV: Tele:

Admin

Fluids:

DX: BS: Res

Dr:

Diet:

HX:

O2:

C

Neuro:

CP

Mobi:

E

L

Res D

W

GU: GI: Skin:

T

Pain: T Iso T

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PATIENTS SIMPLE BRAINSHEET

PATIENT ID LABEL

PATIENT ID LABEL

Meds

Meds

FS

FS

IV

IV

O2

O2

Tele

Foley

BM

Pain Med

Tests

Tele

Foley

Pain Med

Tests

Last Pain Med

Last FS

Last Pain Med

PATIENT ID LABEL

PATIENT ID LABEL

Meds

Meds

FS

FS

IV

IV

O2

O2

Tele

BM

Foley

BM

Pain Med

Tests

Last Pain Med

Tele

Foley

Last FS

BM

Pain Med

Tests

Last FS

Last Pain Med

Last FS

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PATIENTS SIMPLE BRAINSHEET

PATIENT ID LABEL

PATIENT ID LABEL

Meds

Meds

FS

FS

IV

IV

O2

O2

Tele

Foley

BM

Pain Med

Tele

Foley

Last FS

Last Pain Med

Pain Med

PATIENT ID LABEL

Meds

Meds

FS

FS

IV

IV

O2

O2 Foley

BM

Pain Med

Tests

Last Pain Med

Last FS

Last Pain Med

PATIENT ID LABEL

Tele

BM

Tests

Tests

Tele

Foley

BM

Pain Med

Tests

Last FS

Last Pain Med

Last FS

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VERTICAL PATIENTS BRAINSHEETS Pt:

Age:

Rm#

Pt:

Age:

Rm#

Pt:

RN:

RN:

RN:

Dx:

Dx:

Dx:

Coverage:

FSBS:

Labs:

T

Coverage:

FSBS:

Labs:

T

KO2

Na-

Na-

KO2

RR

RR

B/P

B/P

B/P

/10 /10

PO IV

Labs:

T

KO2

Pain:

/10 /10

PO IV

Rm#

Coverage:

FSBS:

RR

Pain:

Age:

Pain:

Na-

/10 /10

PO IV

x0700

x0700

x0700

x0800

x0800

x0800

x0900

x0900

x0900

x1000

x1000

x1000

x1100

x1100

x1100

x1200

x1200

x1200

x1300

x1300

x1300

IV

IV

IV

RATE

RATE

RATE

NOTES

NOTES

NOTES

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VERTICAL PATIENTS BRAINSHEETS Pt:

Age:

Rm#

Pt:

Age:

Rm#

Pt:

RN:

RN:

RN:

Dx:

Dx:

Dx:

Coverage:

FSBS:

Labs:

T

Coverage:

FSBS:

Labs:

T

KO2

Na-

Na-

KO2

RR

RR

B/P

B/P

B/P

/10 /10

PO IV

Labs:

T

KO2

Pain:

/10 /10

PO IV

Rm#

Coverage:

FSBS:

RR

Pain:

Age:

Pain:

Na-

/10 /10

PO IV

x0700

x0700

x0700

x0800

x0800

x0800

x0900

x0900

x0900

x1000

x1000

x1000

x1100

x1100

x1100

x1200

x1200

x1200

x1300

x1300

x1300

IV

IV

IV

RATE

RATE

RATE

NOTES

NOTES

NOTES

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FREEHAND BRAINSHEET DX/Docs:

DX/Docs:

Neuro:

Cardio:

Neuro:

Cardio:

Resp:

GI:

Resp:

GI:

GU:

Skin:

GU:

Skin:

Orders:

Labs:

IV/ Lines:

Meds:

IV/ Lines:

Meds:

Allergies:

Diet:

Allergies:

Diet:

Code Status:

Precautions:

Code Status:

Precautions:

PMH:

Activities/ Misc:

PMH:

Activities/ Misc:

Labs:

pH: pCO2: pO2: HCO3: FiO2:

pH: pCO2: pO2: HCO3: FiO2:

Orders:

DX/Docs:

DX/Docs:

Neuro:

Cardio:

Neuro:

Cardio:

Resp:

GI:

Resp:

GI:

GU:

Skin:

GU:

Skin:

Orders:

Labs:

IV/ Lines:

Meds:

IV/ Lines:

Meds:

Allergies:

Diet:

Allergies:

Diet:

Code Status:

Precautions:

Code Status:

Precautions:

PMH:

Activities/ Misc:

PMH:

Activities/ Misc:

Labs:

pH: pCO2: pO2: HCO3: FiO2:

pH: pCO2: pO2: HCO3: FiO2:

Orders:

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POSTPARTUM BRAINSHEET

Respiratory (Air): cough

dyspnea

rales rhonchi

wheezes

color: lochia:

Cardiovascular (Water): breast engorgement orthostatic hypot'n petechiea edema vertigo

bowel sounds x abd distention diarrhea hemorrhoids last stool

n/v constipation flatus

GU (Elim/Hazards):

abd tone:

urine retention dysuria mL

IV:

MS (Activity/Normalcy):

@

cc/°;

fundal location:

uterine cramping

diastasus rectus

abdominal striae

perineal muscles

Integument (Hazards/Normalcy): breasts: nipples: perineal:

clots

voiding pattern:

with assist? bladder distention oliguria Fr; @

; odor:

appetite/intake:

GI (Food/Elim/Hazards):

foley:

/°; color:

Homan's Sign disphoresis hematomas hemorrhoids

soft firm intact dry swelling bruising laceration episiotomy

° CNS (Social Interaction/Hazards): LOC

tremors

pain

clonus

epidural @

DTR's

;

;

; consistency:

mobility: pigmentation: (nipples, linea negra, striae, chloasma) REEDA affect:

Health Deviation: pumping

postpartum infant security teaching

bonding:

Developmental / Emotional: breastfeeding consult?

need

neo. care (ch. 19)

Sex:

Apgar 1m:

recv'd

social support:

inquisitive?

5m:

Blood Type:

Wt.

Len.

Dir. Coombs:

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POSTPARTUM BRAINSHEET

Student:

Client Initials:

Date:

Room:

Diet:

Nurse:

Allergies: Cultural Background: Primary Language: Date & Time of Birth: Childbirth Prep? Hct: T

Hgb: P

A

Vaginal

Feed:

Breast

Blood Type: L

Cesarean Bottle

Rhogam:

Needed

Rubella:

Imm

HBSAg:

Med Order

1500–1600:

Pos

Given Non-imm Neg

Last Given

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

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PATIENT MEDSURG BRAINSHEET 7

Room: O 2: Tele: P: P: P: Accu

7

7

R: R: R: : 07

S/L: Diet: B/P: B/P: B/P: 1100

9

8

11

R: R: R: : 07

S/L: Diet: B/P: B/P: B/P: 1100

9

8

R: R: R: : 07

1

3

2

Dx:

4

5

T: T: T: 2100

11

12

1

Age:

3

2

Dx:

4

5

O 2: O 2: O 2: 1700

7

Assessment

T: T: T: 2100

11

12

1

Age:

3

2

Dx:

O 2: O 2: O 2: 1700

4

5

6

7

Hx: Assessment

IV: Amb:

WBC

6

Hx:

IV: Amb:

10

7

Assessment

O 2: O 2: O 2: 1700

10

6

Hx:

IV...