Charge Nurse Brain Report
CHARGE NURSE BRAIN REPORT
Report Prepared By: [Your Name], Charge Nurse
I. Patient Information
|
Patient Name |
Room Number |
Diagnosis |
Primary Care Needs |
|---|---|---|---|
|
John Doe |
101 |
Pneumonia |
Oxygen therapy, IV fluids |
|
Jane Smith |
102 |
Post-op Hip Replacement |
Pain management, mobility |
|
Alan Brown |
103 |
Congestive Heart Failure |
Diuretics, daily weights |
|
Emma Davis |
104 |
Stroke |
Physical therapy, speech therapy |
|
Michael Lee |
105 |
COPD |
Nebulizer treatments, O2 monitoring |
|
Olivia Clark |
106 |
Diabetes Mellitus |
Insulin therapy, blood glucose monitoring |
|
Sarah Williams |
107 |
Acute Kidney Injury |
Dialysis, fluid restriction |
|
John Johnson |
108 |
Sepsis |
Antibiotics, hemodynamic monitoring |
II. Clinical Updates
A. Patient Conditions
-
John Doe: Stable, improving with current treatment.
-
Jane Smith: Recovering well, pain under control.
-
Alan Brown: Monitoring fluid balance closely.
-
Emma Davis: Gradual improvement in mobility.
-
Michael Lee: Stable, responding well to nebulizer treatments.
-
Olivia Clark: Blood glucose levels are stabilizing with the new insulin regimen.
-
Sarah Williams: Responding to dialysis, urine output improving.
-
John Johnson: Hemodynamically stable, fever reduced.
B. Recent Changes
-
John Doe: Decreased oxygen requirement.
-
Jane Smith: Transitioning to oral pain medication.
-
Alan Brown: Adjusted diuretic dosage.
-
Emma Davis: Starting new speech therapy exercises.
-
Michael Lee: Increased frequency of nebulizer treatments.
-
Olivia Clark: Adjusted insulin dosage based on latest glucose readings.
-
Sarah Williams: New dialysis schedule implemented.
-
John Johnson: The antibiotic regimen was changed based on the culture results.
C. Test Results
-
John Doe: Chest X-ray shows reduced infiltrates.
-
Jane Smith: Blood tests are normal, and post-op recovery is progressing.
-
Alan Brown: Echo shows improved ejection fraction.
-
Emma Davis: CT scan shows no new ischemic changes.
-
Michael Lee: Pulmonary function test indicates slight improvement.
-
Olivia Clark: HbA1c levels improving, indicating better long-term glucose control.
-
Sarah Williams: Blood urea nitrogen and creatinine levels decreasing.
-
John Johnson: Blood cultures negative, indicating infection control.
III. Staff Assignments
|
Nurse Name |
Assigned Patients |
|---|---|
|
Nurse A |
John Doe, Jane Smith |
|
Nurse B |
Alan Brown, Emma Davis |
|
Nurse C |
Michael Lee, Olivia Clark |
|
Nurse D |
Sarah Williams, John Johnson |
|
Nursing Assistant E |
General Support |
IV. Tasks and Priorities
|
Task |
Priority Level |
Assigned Staff |
|---|---|---|
|
Administer morning medications |
High |
Nurse A |
|
Conduct patient rounds |
Medium |
Nurse B |
|
Update patient charts |
High |
Nursing Assistant E |
|
Prepare discharge for Jane Smith |
Medium |
Nurse A |
|
Assist with mobility exercises for Emma Davis |
Medium |
Nurse B |
|
Monitor blood glucose for Olivia Clark |
High |
Nurse C |
|
Initiate dialysis for Sarah Williams |
High |
Nurse D |
|
Administer antibiotics to John Johnson |
High |
Nurse D |
|
Prepare new admissions (John Johnson, Sarah Williams) |
Medium |
Nurse D |
|
Monitor oxygen levels for Michael Lee |
High |
Nurse C |
V. Unit Summary
A. Bed Occupancy
-
Total beds: 20
-
Occupied: 18
-
Available: 2
B. Patient Flow
-
Admissions: 2 new admissions are expected today
-
John Johnson: Admitted for sepsis management
-
Sarah Williams: Admitted for acute kidney injury
-
-
Discharges: Jane Smith scheduled for discharge
-
Transfers: No transfers anticipated today
C. Resource Management
-
Staffing Levels: Adequate staffing levels for the shift; float nurse on standby.
-
Medical Supplies: Sufficient supplies available, need to reorder IV fluids.
-
Equipment: All equipment functioning well; regular maintenance scheduled for ventilators.
VI. Communication Notes
A. Previous Shift
-
Smooth handover and no major incidents were reported.
-
Alan Brown’s medication dosage was adjusted as per the doctor's orders.
-
Michael Lee required additional nebulizer treatments.
B. Inter-departmental
-
PT department updated on Emma Davis’s progress.
-
The pharmacy was notified of new medication orders for John Doe.
-
Dietary informed of Olivia Clark’s specific meal plan requirements.
-
The dialysis unit was informed of Sarah Williams' new schedule.
C. General Instructions
-
Ensure all patient documentation is up-to-date by the end of the shift.
-
Remind staff to complete patient satisfaction surveys.
-
Check that all emergency equipment is ready and accessible.
-
Communicate any changes in patient status to the medical team promptly.
-
Ensure new admissions are settled and oriented to the unit.
VII. Emergency Protocols
|
Emergency Type |
Protocol Summary |
Contact Information |
|---|---|---|
|
Cardiac Arrest |
Initiate CPR, call code blue, use AED |
Code Blue Team Ext. 555 |
|
Fire Evacuation |
Follow evacuation routes, assist patients |
Security Ext. 333 |
|
Power Outage |
Use backup generators, ensure critical equipment is connected |
Maintenance Ext. 444 |
|
Severe Weather |
Secure all windows, move patients away from windows, and follow the hospital's severe weather plan |
Emergency Coordination Team Ext. 777 |
|
Hazardous Material Spill |
Contain spill, call hazmat team, evacuate if necessary |
Hazmat Team Ext. 666 |
