nursing brainsheets 33 brainsheet database
Post on 12-Jan-2022
10 Views
Preview:
TRANSCRIPT
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!
Happy Nursing!
-Jon Haws RN BSN CCRNCEO/Founder NRSNG.com
p.s. Join us on social media and say “HI” (FB, IG, Snapchat, Twitter, YouTube, Pinterest . . . you get the idea).
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
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
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
ULTIMATE CLINICAL BRAIN SHEET
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
REASON FOR HOSPITALIZATION:
FOCUSED ASSESSMENT:
CONSULTATION/TESTS:
ASSESSMENT NOTES:
PATIENT MEDICATIONS:
NAME REASON CONSIDERATIONS TIME
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
PATIENTS SIMPLE BRAINSHEET
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
PATIENTS SIMPLE BRAINSHEET
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
PATIENTS SIMPLE BRAINSHEET
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
PATIENTS SIMPLE BRAINSHEET
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
FREEHAND BRAINSHEET
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
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:
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:
PMH: Activities/ Misc:
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:
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
POSTPARTUM BRAINSHEET
°
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
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
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
Hgb
HctWBC Plt
Na
K+
Cl
CO2
BUN
Cr Ca
Mg
PO4PTT PT INRGlu
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
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
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
Hgb
HctWBC Plt
Na
K+
Cl
CO2
BUN
Cr Ca
Mg
PO4PTT PT INRGlu
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
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
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.
FULL DNR NONE CONTACT DROPLET AIRBORNE PREVENTION
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
Heparin/Arixtra/LovenoxTEDS/SCDSProtonix/Pepcid
1.2.3.4.
FULL DNR NONE CONTACT DROPLET AIRBORNE PREVENTION
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
Heparin/Arixtra/LovenoxTEDS/SCDSProtonix/Pepcid
1.2.3.4.
FULL DNR NONE CONTACT DROPLET AIRBORNE PREVENTION
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
Heparin/Arixtra/LovenoxTEDS/SCDSProtonix/Pepcid
1.2.3.4.
5 PATIENT VERTICAL BRAINSHEET
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
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
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
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
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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?
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
4 PATIENT OB BRAINSHEETS
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
SIMPLIFIED BRAINSHEET
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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
©2016 TazKai LLC | NRSNG.comMore FREE nursing school aids at NRSNG.com
Disclaimer information at NRSNG.com
Stay Organized on the Floor with the Nursing Brain Sheet Pack from NRSNG.com. Visit NursingBrainSheets.com to get 35 Nursing Brain Sheets
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:
top related