HTML Preview Nursing Brain Report Sheet page number 1.
BRAIN SHEET – NEW SHIFT REPORT
Room:____________ DATE:____________
Patient______________________Age___Sex____ Admitted: _____HD:________LOS:_______
Diagnosis:__________________________Procedure___________________________________
Comorbid Conditions\Hx:_____________ Code Status:______Allergies____________________
______________________________________________________________________________
SIGNIFICANT 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: O
2
BS: Mask:
Coughing Sputum Triflow
Chest Tubes: Bipap:
ABG: Mode: Cuff Pressure
FiO
2
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 PTT CPK CKMB%
Mg PT CKMB TROP