Re: Medical-surgical Nursing Sheet
Donald
Having a Nurse's Brain for your patients will help you better prioritize your day. You might want to come in early to research patients and plan your day, so you can fill out some of this info before you get a report from the previous nurse.
We've provided a ONE page downloadable Nurse's Brain document. However, some nurses use page or page for their patients. Feel free to download this document and use it as-is OR make a copy and modify it to meet your needs.
This Nurse's Brain is modeled on what Cathy used in a Med-Surg/Tele/Stepdown unit. For Maternal Newborn, you would need something totally different. Check back for specialized Nurse's Brain documents to be added in the future.
Hi, I'm Cathy, and in this video I am going to talk about the Nurse's Brain, which is a term we use to refer to a piece of paper, or several pieces of paper, that we use to capture really important patient information to keep us organized. Having a Nurse's Brain for your patients will help you better plan and prioritize your day. It can also help you give more effective reports to your oncoming nurses, to your CNA, or to a doctor.
So, in this video, we'll talk about the Brain and then in subsequent videos in this playlist, I will be talking about how to give a good report to those different people on your team. So we have posted an example of a Nurse's Brain that I like on our website LevelUpRN.com. It is a full page for one patient which is what I prefer. However, I know some nurses like to have two patients per page, or sometimes even four patients per page where there's like a quarter of the page for each patient. You are free to, of course, do whatever works best for you. You can save this Nurse's Brain and modify it to your heart's content.
Okay, so here is the Nurse's Brain that I have uploaded to our website. Over here on the left side is where we have the patient name, their sex, their age, their date of birth, their medical record number. This information can often be found on the patient stickers that are available on most units. So you can simply get one of those stickers for the patient and slap it right over this area. Instead of writing out this information.
Then here in the middle, we have the patient's room number, we have their code status, so whether they're full code, or DNR, which is always really important to know right off the bat, so that if your patient goes into cardiac arrest, you know whether to call a code and start CPR or to not do that. You need to really understand their preference.
And then you can write down the patient's doctor, like their hospitalist. And then if they have a surgeon assigned to their case, or if they're, you know, a post surgery patient, then you can put their surgeon there. And if there are any other important team members that you need to capture, you can put it here on this line.
And then over here we have the patient's Admitting Diagnosis, what brought them to the hospital, their primary problem and why they're there. And then over here, we have Other Diagnoses and Patient History. So some patients come in with a huge laundry list of co-morbidities. So I urge you to really be selective here on capturing just the things that are going to be really important to know when you are caring for the patient. So just a little room here to capture that.
And then we have the Labs. So you'll definitely want to just look up the patient's labs. First thing to see if there's anything out of whack and if you're going to need to request an order for electrolytes or blood products or anything like that from the doctor. So I know some Brains have like that little tree that you can use to put in electrolytes and blood levels. I don't prefer that, but you certainly can put that into this space instead. So here we have the most common electrolytes, and then we have, you know, basically CBC levels.
And then the next area here is for Vital Signs. So depending on whether your patient's on telemetry or not, it really dictates how often you need to take vital signs. So if you need to take it like every four hours, you can put 8am here and then put in their vital signs and then put noon here, 12 o'clock, put in the vital signs, 4pm or 1600 and put in the vital signs. So it'll let you take a look here at their vital signs over time. So if you see their blood pressure starting to tank over the course of the day, that's important information and something you're going to want to notify the provider about.
Okay, then down here we have Medications. The way I like to organize my Nurse's Brain and kind of track that is, I circle the times where I have medications I need to give the patient. And if there are certain of those times where I need to give an antibiotic, I put like a little "A" by it or a little star, something to indicate that there's an antibiotic that needs to be given at that time, so I can make sure I hit as close to that time as possible, because antibiotics are more time sensitive. So if I have 9am meds I would circle 9am and then if I have 1300 meds, I would circle that. And again, if antibiotics are to be given at that time I put like a little "A" or a little star there. And then I don't like, write out all of the medications because for some patients, it's like 20 different medications. I can, you know, look it up on my Rover on my computer and easily take a look at that list there. So for my Nurse's Brain, I just need to know what times I need to give meds.
And then I also want to keep track of the as needed medications or PRN Meds. So, does this patient have pain medication available for pain? Do they have nausea medication as needed, anxiety medication, those type of things. And then I also keep track here about what time I gave them their last pain medication, so if someone's in a lot of pain and they're wanting their pain meds every three hours as it's available, I definitely keep track here of when I gave them their last dose.
And then moving on here, we've got their IV Access, like, do they have a PICC line? Do they have a peripheral line and where is it located? And how big is it? And then if they-- if the patient is getting continuous IV fluids, then I'll put what that is, such as normal saline, and at what rate they are getting those fluids.
So for Respiratory, if the patient is getting oxygen therapy, then I would select "Yes" here and I would put how many liters per minute they're getting through the nasal cannula. Or if they have a mask or some other thing I would make note here as well.
And then in terms of their Neuro status, I would make mention here of their level of consciousness. This is something you'll probably need to get from the previous nurse. And then of course, do your own assessment and see if the patient is alert and oriented times four, or maybe it's three, maybe it's two, maybe it's one, maybe it's zero. You need to just find out, does the patient know their name? Do they know their date of birth? Do they know where they are? Do they know what month or year it is? Those are some typical questions that we asked to really gauge the patient's level of consciousness.
And then we have the Musculoskeletal system. And we really need to determine right off the bat, is this patient independent? Can they get up without falling and, you know, go to the restroom by themselves? Or do they require assistance? If they need assistance, is that a one person assist or a two person assist? Or are they on bedrest, so it's important to know that right out the gate so that you can set the bed alarm? If the patient should not get up independently, you need to make sure they have a fall risk light bracelet on, if they are at risk for falls, and you definitely need to ask for help, if needed if assist is required for that patient.
Okay, and then moving on to the Gastrointestinal and Urinary system. You just want to know the patient's diet. Are they NPO? Are they on a dysphasia diet? Or are they on a normal diet or diabetic diet, it's important to know that. It's especially important to know if they are on like fluid restrictions or salt restrictions. If your patient's on fluid restrictions, you're really going to want to coordinate with your CNA and make sure that you guys are tracking all the fluids that the patient is getting. Because patients often who are on fluid restrictions, they will ask for water from like everybody. So they'll ask the nurse, they'll ask the CNA, they'll ask the occupational therapist, they'll ask the wound nurse. They'll ask everybody. And so you just, you got to make sure you understand if they have any restrictions and definitely enforce those. Find out when their last bowel movement is. If you go up and down the halls at the hospital around 7:30 any morning, you can hear nurses asking that question up and down the hall to all the patients. So find out when their last bowel movement was. Find out if they are incontinent. So are they incontinent of urine, bowel or both? And then do they have a Foley catheter in place? Alternatively, do they have a condom catheter in place? A Purewick? Hopefully you guys are familiar with this. If not, it's a device that basically provides suction so if they urinate in bed, it gets sucked into the bedside-- a bedside container. So it looks like a--it looks like a giant tampon basically, but it doesn't go inside anything. It just kind of lays along the perineal area and sucks urine out. And then a Dignicare is named this but it's not too dignified. It's basically a fecal containment system. It's like a tube that goes up the patient's anus and collects fecal matter when they're having like a lot of loose bowel movements. Not very comfortable for the patient and often they don't work very well. Just my opinion.
Okay, and then over here we have the skin right? So you want to when you do your full assessment, you want to make sure you identify any wounds or pressure injuries that the patient has. So pressure injuries is the more accurate term we use today for what people previously called bed sores or pressure ulcers. I'm a wound nurse so I'm telling you right now, pressure injuries is kind of what we're trying to move the industry towards and that's what you'll hear more and more. So you'll, you know, capture any injuries they have here like, "Stage 2 coccyx pressure injury," that type of thing.
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