Nurse Brain Sheets - Shift Hours printable pdf download

BRAIN SHEET WITH SHIFT HOURS

Pt/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: 

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

IVF 

Nausea/vomiting 

Gtube/Jtube/PEG 

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: 

IVF 

Last BM: 

Tube Feed: 

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: 

Dates:

Retractions/Grunting 

Cath Lab? 

Inserted 

Nasal Flaring 

Angioseal? Lt/rt groin 

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 

Nurse Brain Sheets - Shift Hours

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