A Nurse’s Brain is a term for a piece of paper, or several pieces of paper, that we use to capture really important patient information to keep us organized.
There are sections for key areas like patient history, meds, body systems status, and more.
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.
It can also help you give more effective reports to your oncoming nurses, to your CNA, or to a doctor. If you learn to do this well, your coworkers will respect the care and organization you put in to making their lives easier, which will improve nursing relationships with those coworkers. It also helps you take better care of your patient — because you are more organized and can clearly communicate what you need from the CNA, doctor, or oncoming nurse.
Watch the video to see Cathy walk through each area of her Nurse’s Brain and tips on important things to consider for each section.
In the following videos in this series, she will talk about what to include and NOT include in your report to CNA, doctor, and RN.
Make a copy of this free resource, or you can download it as a PDF.
To edit this Google Doc, select File -> Make a Copy. To save it to your computer, select File -> Download and choose your format.Get the Nurse's Brain
We've provided a ONE page downloadable Nurse's Brain document. However, some nurses use ½ page or ¼ 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 MedSurg/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.
Let us know in the comments if you found this useful and if you’d like to see more specialized Nurse’s Brains.
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.
So the Nurse’s Brain that we've posted is really focused more on a MedSurg or Tele floor or even a Stepdown unit. So if you need a Nurse's Brain for like, a Maternal Newborn unit, then this probably is not going to work for you. However, if you find this is helpful, and you want us to make more Nurse's Brains for different types of units, we might be able to do that. Be sure to leave a comment, give us your suggestions and let me know how you like this Nurse's Brain. And as you use it, keep in mind that one thing you may want to do, which I always did when I worked on a MedSurg/Tele floor, because you may want to come in a little early before your shift, to look up some important information about your patients that you are assigned for the day. So you can kind of get a little bit of a head start and a better understanding of what you're walking into, versus walking straight into getting report from the previous nurse. So I know a lot of nurses do that. And nursing students do that as well. Some like to, you know, roll in right at 7am and just walk right into report. And if that's your jam, if that's how you like to do things, that's totally fine. It's like whatever works for you. But for me, like I said, I like to come in early, get a little organized, do some planning and fill out my Nurse's Brain as much as possible for the patients I'm assigned over the course of that day.
So now we will take a look at this specific Nurse's Brain. I'll talk about the different components and why I set it up the way I did.
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.
Then we have what isolation precautions they're on. So if they're not on any, you can circle None here, we also have Contact, Droplet and Airborne precautions.
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.
And then down here, I will put in some important information about the different body systems.
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 for the Cardiovascular system, I would note whether that patient is on telemetry or not.
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.
If your patient is diabetic or receiving like some kind of steroids and are needing to get blood sugar checks, then you can mention or track here whether they are getting basal correction, or they're getting nutritional coverage, and then you can kind of track their blood sugar levels here, again to see trends and just to track what those are.
And then, as you're getting report, you want to determine if the patient has any tests or procedures scheduled for your shift so that you can make sure to keep track of that.
And then are there any To-do items or Notes? Are there things that you need to get done or find out for the patient? You can track that here. And then when you go in to do your head-to-toe assessment on the patient, then this is the area I would use to track any abnormal findings. So I always track things that are out of range or abnormal. So I'm not going to write in here that they had normal breath sounds or normal heart sounds or clean and dry intact skin. But what I do use this space for is tracking things that are abnormal. So if I heard crackles in their lungs, if they have edema, if their bowel sounds are hypoactive, I put the unexpected findings down here at the bottom.
So this sheet really gives me all the information I need to really understand the patient's situation, be able to give report to other nurses or doctors and just really helps me stay organized with the day in terms of medications and such. So I hope that you find this helpful too. Definitely leave us some feedback. And in my next video, we will talk about how to give a good report, which is so important so stay tuned!
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by Meris Shuwarger Jun 14, 2021
by Meris Shuwarger Jun 07, 2021
For nurses-to-be, Cathy's FREE videos are a great place to start (don't miss the inspiring stories and helpful hints in the comments).