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    Nurse Brain Sheet New Shift Report

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    RosemaryCastro
    This document contains a summary of a patient's hospital course. It includes [1] the patient's diagnosis, medical history, and code status; [2] assessments of major body systems including neurologic, cardiovascular, pulmonary, and gastrointestinal; and [3] the patient's treatment plan and any variances from the plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nurse Brain Sheet New Shift Report

    Uploaded by

    RosemaryCastro
    972 views1 page
    This document contains a summary of a patient's hospital course. It includes [1] the patient's diagnosis, medical history, and code status; [2] assessments of major body systems including neurologic, cardiovascular, pulmonary, and gastrointestinal; and [3] the patient's treatment plan and any variances from the plan.

    Original Description:

    Nurse Brain

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    This document contains a summary of a patient's hospital course. It includes [1] the patient's diagnosis, medical history, and code status; [2] assessments of major body systems including neurologic, cardiovascular, pulmonary, and gastrointestinal; and [3] the patient's treatment plan and any variances from the plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    972 views1 page

    Nurse Brain Sheet New Shift Report

    Uploaded by

    RosemaryCastro
    This document contains a summary of a patient's hospital course. It includes [1] the patient's diagnosis, medical history, and code status; [2] assessments of major body systems including neurologic, cardiovascular, pulmonary, and gastrointestinal; and [3] the patient's treatment plan and any variances from the plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Rosemary's Brain for ______________

    Room:____________
    DATE:____________
    Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______
    Diagnosis:__________________________Procedure___________________________________
    Comorbid Conditions\Hx:_____________ Code Status:______Allergies____________________
    ______________________________________________________________________________
    SIGNIFICANT HOSPITAL HISTORY

    Neuro:
    Orientation:

    PLAN:

    VARIANCE

    Cardiovascular:

    PLAN:

    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+:
    MBs:
    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:

    BODY SYSTEMS
    Neuro:

    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

    Mask:
    Triflow

    Respiratory

    PLAN:

    VARIANCE

    GI:

    PLAN:

    VARIANCE

    Cuff Pressure

    GU:
    I&Os

    PLAN:

    VARIANCE

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

    Variance to Discharge Plan: Barrier


    Resolution:
    Consults:

    Special Needs:

    Ca

    PTT

    CPK

    CKMB%

    Mg

    PT

    CKMB

    TROP

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