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Discussion

Brain Sheets?

Hi...I'm a new grad going through general orientation this week with other new RNs. Basically just listening to speakers all day about policies & procedures...BUT next Monday I start on the floor with my preceptor. Yay! I think I have everything I need to start, except brain sheets. There are some standard ones available, but most nurses make their own (I've worked there ad an aide for several years & that's how I know) I really don't know what all to include to make my own. I will be working on a basic medical unit 12 hr night shifts. My first 3 weeks I will be starting on days so I can get familiar with admission & discharges. Does anyone have any brain sheet templates they would like to share? I've Google'd them but have not seen anything I like so far. Any input would be greatly appreciated!! Thanks :)

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    A lot of units have their own, so I would wait and see.

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    • Author

    OK. Thanks anyway...

    I just thought I would check here. I saw some posted a while back but I can't find them.

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    It will all depend on the patient you have and unit you work on. For my unit we have every 4 hour assessment.

    I will just tell you how my paper works.

    On the back I put 3x for every assessment.8am 12, and 4pm

    Bp

    Hr

    R

    T

    O2

    Next to this with every assessment I put what I found during my assessment. Ex. Pt has pain of 2 bilateral +1 pitting edema, crackles in bases of lungs. Positive bowel sounds. Then I put how much their i/o is. Ex : 450 out. 240 in PO. Or 300 in IV. If they are a turn q2 I also put the times hat I need to turn them so I don't forget. Ex 0800 1000 1200 etc. and what position I left them in ex. Supine , lying left, lying right , etc.

    and if the patients has any miscellaneous orders or tasks needed I put simply a "to do" list on the bottom right. And then on the back of the paper I put my meds and the times they are due so I don't forget and nurses will always appreciate you reading the doctors notes and giving them the big picture of the patient and the progress. History of the patient what brought them in wha was done.

    Long explanation but hope that helps

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    • Author

    Thanks! That helps a lot :)

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