Every nurses’ brain (aka their notes and to-do list for each patient) is going to be somewhat different and as a new nurse it might be difficult to find what works best for you. This post will show you what to include on your brain as well as give you a free example of an organizational brain template!
What Should Be On My Brain?
Depending on what unit you’re working, you may need to check the vital signs every hour, every 4 hours, or every 6 hours and your brain should reflect this. If you’re on a neuro floor, then your neuro assessments are going to need to be on your brain. Whereas if you’re on a tele floor, your EKG strips are going to need to be read every couple of hours and again should be reflected on your brain.
Whatever the goal of your shift may be, you are going to want to adjust your brain accordingly. Which means your brain can (and should) be different for every patient. The following are some important things to include on your brain to help you stay organized.
For more information, visit What Makes a Good Med Surg Nurse?. And follow along for the Specialty Nursing Series!
Patient Name & Room Number
I always put this information in the same spot on each of my patients’ brains. It makes it easier to flip through my papers to find the brain I’m looking for. For me, the patient name is located across the top of my paper and the room number is in the top right corner (see below).
Precautions
Is your patient on contact, droplet, or airborne precautions? This is super important to know before entering the room so that you can don the correct personal protective equipment, aka PPE.
For more precaution information, visit How To Don and Doff PPE for Medical Professionals.
Vital Sign Times
As previously mentioned, some of your patients are going to need their vitals taken more often than others. As a reminder, I write down the times each patients vitals need to be checked right under the patients’ name (see below). Once I am done with each set of vitals, I cross off the time.
Pro Tip: Always talk with your CNA/PCA at the beginning of the shift and see what times they are able to check what patients vitals for you. There’s a chance they could be down a CNA and may not be able to check any of your patients vitals. So communicate this at the beginning of your shift to prevent headaches later on.
Scheduled Medication Times
Depending on how many medications you have for each patient, I like to write down the time each medication is due in my hourly schedule (see below). If the patient only has a few medications, then I write down the time as well as what medication is due. But for other patients who are getting all sorts of medications all around the clock, this simply isn’t doable.
For those patients, I simply write down the time I plan on clustering my care for medication passes. For example, if they have meds due every 15 minutes in the 2300 hour, I’m not going to go in there 4 times. I’ll mark it on my brain to go in there at 2330 and give all four of the medications at that time.
Be sure to visit Nursing Fundamentals: A Guide to the 10 Rights of Medication Administration for more med pass info.
Pain? PRN Medication Times
Pretty much right off the bat you’ll be able to tell if a patient is going to need round-the-clock pain medications. If this is the case, I like to discuss this with the patient.
Say they have PRN Morphine that can be given every four hours. Talk this through with your patient to make sure you are both on the same page. Ask them if they are going to want to be woken up for pain meds every four hours or if they want to wait and call you when they’re in pain. Once you have developed a plan and you’re both on the same page, take your newly developed pain plan schedule and write it on their whiteboard AND on your brain. This way you both know exactly what the pain plan is. And if the patient forgets, they can reference the board!
Pro Tip: Take this time to educate your patient on the effectiveness of their pain medication and potential side effects. Then come up with a realistic pain relief goal together. The more the patient is involved in their pain management, the better they’ll feel, physically and mentally.
See more on taking care of a patient in pain at Nursing Fundamentals: A Guide to Pain and Patient Education: How to Effectively Manage Acute and Chronic Pain.
IV Fluid and Rate
This is something a lot of new nurses glance over. They see an order for NS at 100 mL/hr and they see the IV pump set up and running but they forget to check the fluid and the rate!
This is so important! Say they start going into fluid overload and you realize the rate was set way too high by the previous nurse… Well now it’s on you. So make sure you write this information down on your brain and check it every shift for every patient.
Pro Tip: Do this check with the nurse who’s giving you report so if you do find a discrepancy, they’ll be aware of their mistake and you can fix it together. If you forget to do this during change of shift report, then make sure to do it during your assessment. All while making sure the line is patent and the IV site isn’t irritated or infiltrated.
Pro Tip #2: Again you can take this time while assessing their IV to educate the patient. Let them know that if their IV site becomes red, irritated, or swollen to ring their call bell. That way you can come check on it and get ahead of any problem that might be occurring. This is especially important if running a medication that might be harmful to their veins.
Assessment Abnormalities
Charting while doing your assessment isn’t usually an option for most nurses. Typically, you want to do your full assessment and take notes on what you’ve seen.
Since taking notes on every system would be super time consuming, only take note of any assessment abnormality. This way, when you go to chart, you can put WDL (within defined limits) for all systems you didn’t take notes on.
If you’re charting and you see you’re putting WDL for something that another nurse noted an abnormality for, then just go back and reassess that one area. If you’re right saying it’s WDL, don’t change your charting just to match the previous nurse. Only chart what you’ve actually assessed and seen to be true.
Do They Have Anything Attached To Them?
Take notes on anything the patient has attached to them. This technically counts as an assessment abnormality because if they were otherwise healthy, they wouldn’t have anything dangling off. Do they have an IV? An ostomy bag? Are they on oxygen? Do they have a bandage covering a wound?
These are all assessment abnormalities that should be documented on in their chart. So write all this down and transfer it into your charting later in the shift.
Wounds
A wound is again, you guessed it, an assessment abnormality. Make sure you note a) when the last time the dressing was changed, b) if it needs to be changed during your shift, and c) what it needs to be cleaned with.
If it’s not supposed to be changed during your shift, or if there’s specific instructions for a wound care nurse to change it, then there is no need for you to look under the dressing. Too many unnecessary dressing changes open the wound for bacteria to enter, which we obviously don’t want.
In your charting, simply assess the bandage and chart on that. Is the bandage saturated? What does the drainage look like? Color and thickness. Did you mark the drainage on the bandage? Did you need to reinforce the bandage during your shift? What does the skin around the dressing look like? Is the wound causing the patient any pain or discomfort? All of these are important to note when dealing with a patient who has a wound.
Cardiac Monitoring
Cardiac monitoring should be noted in the section of, “do they have anything attached to them”. If they do in fact have a cardiac monitor, then you’re going to need to interpret the results of their EKG strips. Check with your hospital policy to see how often these strips need to be read. Also note what their previous strips have indicted. Is their cardiac function getting better? Or is it declining? Is this something that the doctor needs to be made aware of or do they already know? Have they been normal sinus rhythm for a while? Can they be taken off the monitor? These are all good questions to be thinking when assessing someone with a cardiac monitor.
Are They Total Care? Ambulatory? Independent?
You should be made aware of the patient’s mobility status during report. And the patient should already have whatever they need to ambulate at bedside. But, if for some reason they don’t have what they need (i.e. a walker, cane, etc.), make sure you get them whatever they need to safely ambulate. This will help prevent a fall on your shift. Be sure to chart all of this accordingly.
Pro Tip: If the patient is a total care, make sure to chart all your turns and into what position. Sometimes your CAN/PCA will do this for you, but if not, make sure to chart it yourself. Also make sure you protect your patients skin as much as possible; likely even apply Mepilex to any bony prominence.
Charting
Since you can never sit down and do all your charting at once, I always write down all the tabs I need to chart on in the left hand corner of my brain and check it off once it’s charted on (see below). This way, when you get pulled away from charting (which happens all the time), you can easily go back and find exactly where you left off charting and for what patient.
Pro Tip: Invest in a nursing clipboard to hold onto your brain. Also be sure to check out 10 Best Amazon Must Haves For New Grad Nurses.
Goals
Every shift you should have at least one goal per patient. Sometimes these goals will be achieved over a few days and other times over just one shift. Either way, you should communicate these goals with your patients. And if you have time, write these goals on the communication white board so that both you and your patient are on the same page.
For example, a patient in excruciating ten out of ten pain goal might be to get their pain less than six for the remainder of the shift. Once set, write this goal on their communication board and on your brain. Then, when you go to write your nursing note, you can mention this goal and write whether it was achieved or not and what your recommendation for the next nurse is.
And that’s it! Keep scrolling for the template.
If you’re working nights, you’ll find these posts helpful:
- What Do Night Shift Nurses Do? An Hourly Survival Guide
- Adjusting to Night Shift
- I’m a Night Shift Nurse, What Should I Do with My Days Off?
Also be sure to check out these helpful new grad posts:
- How to Organize Your 12-Hour Nursing Shift
- 16 Things You Need to Bring to Clinical
- Nursing Bag Essentials for New Nurses
- Essentials of a Good Bedside Handoff Report
- Imposter Syndrome as a New Nurse
Here’s what my Organizational Brain Template looks like!
