Situation:Patient Name:_________Allergies:_____________Diagnosis:____________

Today’s Date:_______Admin date:________Code Status:_________SCDs: y/n

Fall Precautions:Restraint Being Used:

Background:Medical History:

Current Treatments/Interventions:

Assessment:Neuro:

Respiratory:

Cardiac:

GI/GU:

Musculoskeletal:

Skin:

Dressing Change Due:

Psychosocial:

Xray Results:

Lines/Fluids:

IV dressing insertion date:

Last Vital Signs:Temp:___HR:_________ BP:________RR:________ Pain Scale:___O2 Sat:________Last pain med given:_____Glucose Monitoring:______Last Glucose Given:_______Abnormal Labs:

Recommendations:Goals:

Consults:

Tests/Treatments:

Discharge needs

NURSING: Head to Toe Assessment

Patient Initials: ______Room #_______Most Recent Diagnosis:____________________________________________________________________________ Time of Assessment________

Vitals IV Medications Due 5Ps0800 1200 Site #1:

Date Inserted:________Location: ____________ Solution/Rate:_________Site Assessment:□Clear □Redness □Pain □Warmth □Swelling □DrainageSite patency for a lock device: ___________

Site #2: Date Inserted:________Location: ____________ Solution/Rate:_________Site Assessment:□Clear □Redness □Pain □Warmth □Swelling □DrainageSite patency for a lock device: ___________

0730 0800 0830 09000930 1000 1030 11001130 1200 1230 1300

Medication Rights: 1Patient, 2Med, 3dose, 4route, 5time, 6rationale (7based on the right assessment data), 8documentation, 9reaction.Reminder: 10educate your patient and they have a 11right to refuse!

pain, positioning, personal items, personal needs, privacy.

Labs Blood Glucose0730 value: ______Correction dose: type of insulin_____units ______Meal Dose: type of insulin_____units_______Should the meal dose be held? If so, why?________________________________________________________Percentage of meal eaten _______%

1130 value: ______Correction dose: type of insulin_____units ______Meal Dose: type of insulin_____units_______Should the meal dose be held? If so, why?________________________________________________________Percentage of meal eaten _______%

Pain AssessmentScore on scale of 0-10:_____ Acceptable level of pain:______ Name of pain med and time med was administered:_______________________________________________________Aggravating Factors: Alleviating Factors (non-pharmacologic):

What did you do to provide comfort for this patient?

Location: _____________________________________Pain is: Acute Chronic Continuous Intermittent Description of pain: Dull Sharp Stabbing Burning Throbbing PCA: Yes NoLast pain med given: _______ time: _____ Was it effective?_____________What did you do to alleviate this patient’s pain?

Neurologic AssessmentOriented to: Person Place Time Situation Responsive to commands: Yes No PERRLA R Pupil Size_____mm L Pupil Size_____mm Brisk Sluggish Communication/Speech: Clear Appropriate for age Slurred Non-Verbal Is this patient able to feed her/himself? Yes No Does this patient have a history or difficulty swallowing? Yes No HOB at 30 Other:

AROM or PROM: Head/Neck Right Arm Left Arm Right Leg Left Leg Grasp Strength: _____/5 Pedal Press Strength: _____/5Cardiovascular AssessmentCapillary Refill: < 2 Sec. > 2 Sec Apical Pulse Rate: _____/min Regular Irregular Apical/Radial Deficit Abnormal Heart Sounds orthostatic blood pressure/HR if indicated per MD or med administration (check patient’s activity order before orthos)Lying HR_______, BP_______ (____:____am/pm)Sitting HR______, BP_______Standing HR____, BP_______Peripheral Pulses: Right Radial:Palpable Doppler Absent Left Radial: Palpable Doppler Absent Right Pedal: Palpable Doppler Absent Left Pedal: Palpable Doppler AbsentEdema: RUE: Yes No Pitting _____/4+ LUE: Yes No Pitting _____/4+ RLE: Yes No Pitting ______/4+ LLE: Yes No Pitting _____/4+Respiratory AssessmentRespiratory Rate: ____/min Respiratory Effort: Relaxed and Regular Labored Breathing DyspneaBreath Sounds: Upper Right: Clear Diminished Crackles Wheezes Absent Rhonchi Middle Right: Clear Diminished Crackles Wheezes Absent Rhonchi Lower Right: Clear Diminished Crackles Wheezes Absent Rhonchi Upper Left: Clear Diminished Crackles Wheezes Absent Rhonchi Lower Left: Clear Diminished Crackles Wheezes Absent Rhonchi If cough is present: Productive Nonproductive If productive : Color______________ Consistency_____________Pulse Ox: ______% Supplemental Oxygen:_______ Incentive spirometer use: how many times per hour?_________ maximum volume reached? _________mls

NURSING WORKSHEET

STUDENT'S NAME_____________________________ DATE_____________________

PATIENT'S INITIALS_______ AGE_______ SEX______

ROOM #_________________ ADMISSION DATE___________

PRIMARY LANGUAGE_____________________ ALLERGIES________________

ADMITTING DIAGNOSIS____________________________________________________

HISTORY OF PRESENT ILLNESS: [Include risk factors, smoking, ETOH use, & precipitating event to admission.]

CURRENT & PAST MEDICAL PROBLEMS: [eg. HTN, DM, Angina, physical limitations to include hearing loss, blindness, amputations, etc]

PATHOPHYSIOLOGY OF ____________________________________________________

TEXTBOOK DESCRIPTION OF PATHOPHYSIOLOGIC PROCESS

CLINICAL MANIFESTATION

ETIOLOGY

SURGERY1. PREVIOUS SURGERY [PLEASE LIST DATES & SURGICAL PROCEDURES]

2. CURRENT SURGERYA. DATE & TYPE OF SURGERY

B. NUMBER OF DAYS POST OP________ EBL________________

C. PROVIDE A GENERAL DESCRIPTION OF THE SURGICAL PROCEDURE

DIAGNOSTIC TESTS & RESULTS [eg. X-rays, biopsy, UGI series, occult blood tests, paracentesis, etc.] LIST ALL TESTS BELOW.

TEST DATE & RESULT REASON FOR TEST

PLEASE LIST ALL INTERVENTIONS – i.e. Dressing changes, Drains & tubes, (chest tubes, foleys, NG tubes, T-tubes, etc), Respiratory TXs, Finger stick glucose, special equipment (i.e. special beds, walkers, heating pads, etc.) etc.

INTERVENTION RATIONALEACTIVITY LEVEL:

DIET:

IV SOLUTION & RATE:

TYPE OF VASCULAR ACCESS DEVICE:

TUBES: [list all tubes, drains, etc.]

OTHER

Learning and Teaching Strategies for Laboratory Interpretation and Medication Administration for Students

Laboratory Interpretation Strategies

Knowledge: Nurses are geared to fill the gap of physiology knowledge and patient assessment. Fundamental nursing students must start to do this early as it needed for safe patient care. With that in mind, here is the research and explanation for how student nurses should think of laboratory values and the level it is to be practiced before they are licensed and independent in practice. NURSING is not about being perfect but trying your best to example how to be as excellent as you can at your level of knowing.

Attitude: "The proposed strategy, based in part on the work of Wissman and Wilmoth (1996), may help decrease the delay between acquisition and application of knowledge. It also encourages nursing students to begin seeing the "whole picture" of their clients, beyond a name and diagnosis" (Quality and Safety Education for Nurses Institute, 2016). The Joint Commission (2017):

National Patient Safety Goal #2: to improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis. Elements of Performance: Critical results of tests and diagnostic procedures fall significantly outside the normal range and may indicate a life-threatening situation. The objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.

Use the knowledge and attitude, as mentioned above, to attain critical thinking and keep patients safe. It is called the SBAR method for laboratory interpretation, see below. 

Skill: Here’s an example:

The student writes: “low H/H:  due to acute blood loss.”

Professor response: "I do not see where there is overt/covert blood loss in the patient’s assessment findings, how is this low H/H pertinent in your patient?” 

Use the SBAR method for understanding laboratory values.

(Situation): Mr. RR, a 68 y/o male who is Full Code & has No Known Allergies. Mr. RR is here for V fib & cardiac arrest. Info is obtained from the medical record.

(Background/ History): He has a h/o (history of) 1) Ischemic heart disease s/p CABG x 1 and has a cardiac stent 2) Cardiovascular disease 3) Aortic valve sclerosis w/ mild aortic insufficiency – diagnosed in 2005 4) DM II 5) morbid obesity w/ BMI > 40 6) Hyperlipidemia 7) GERD.Info is obtained from the medical record. Use the current diagnosis & acute problem rather than stating an abnormal value is d/t past medical hx (90% of lab abnormalities are d/t acute processes not historical ones.) You must apply concepts from previously learned

pathophysiology to understand highs and lows.

(Assessment – define the lab you are trying to interpret): Student writes: A: Hemoglobin: measures of the iron-containing pigment of RBCs and the concentration of RBCs, respectively, that carries O2 to the tissues (Nursing Central, 2016). Define what hemoglobin is from Nursing Central.

Student writes in the “A” portion of the worksheet: “I have trended the H/H & found it to be low for the past 9 days. The patient has had numerous blood draws. The patient has experienced a state of shock.” The info above is obtained from medical record and your assessment.

**Students’ interpretations are developed from using the nursing process and scientific inquiry.

As you create clinical reasoning regarding acute illnesses, you will relearn and revisit concepts contributing to a low hemoglobin value. Note well: NOT all abnormal labs are the result of medications. **The process of anemia (a low H/H) is caused by the body’s response to the acute or chronic processes (Lewis et al., 2011; Urden et al., 2014).

(Recommendation:)

Student writes: Trend the H/H values. Suggest using pedi tubes and/or decrease frequency of overall phlebotomy draws. Place on fall precautions and trend VS. Consider what are factors contributing to the acute or chronic process and write this in your recommendation. Recommend what will you monitor as the nurse (i.e. VS, sat, RBC indices, overt and covert signs of bleeding.) Place assessment findings in your worksheet and how often you recommend to reevaluate if the hemoglobin level.

This info comes from you understanding how to reason and create patient safety, using the nursing process. This will lead you to applying old concepts to new learning ones, the very definition of knowledge acquisition and application.

Medication Administration Learning Strategies

Knowledge: Nurses are geared to administer medications via the 8 rights for medication administration but to also fill the gap of pharmacy knowledge and patient assessment. With that in mind, here is the research and explanation for how student nurses should think of medications and the level it is to be practiced before they are licensed and independent in practice (QSEN Institute, 2014).

Attitude: "The proposed strategy, based in part on the work of Wissman and Wilmoth (1996), may help decrease the delay between acquisition and application of pharmacology knowledge. This strategy can also be used to emphasize the importance of client education for medication regimen safety and compliance. It also encourages nursing students to begin seeing the "whole picture" of their clients, beyond a name and diagnosis" (QSEN Institute, 2016). This method is called the SBAR method for medication administration. 

Skill:The student states the med Lasix is a "diuretic."

Your professor states, "You are only defining the meds, not telling me why this patient is needing the medication." 

Use the SBAR method for understanding medication administration for that patient below.

(Situation): pt is admitted with chest pain

(Background): edema and CHF

(Assessment): the patient's current input is greater than output & weight has decreased by only 0.5kg since admission, CXR is report to have infiltrates, patient has a congestive cough and is short of breath on exertion. He has crackles bilaterally and sat maintained at 92%. 122/86, HR 84, RR 20, T=98.8, and negative orthostatic blood pressure readings.

(Recommendation): Student writes: “I would give the Lasix.”

(If you do not want to give the Lasix, you must support that decision with clinical reasoning: Here is an example of why a nurse would hold a diuretic: “I would not give Lasix due to Na+= 154, BP=84/42, HR=110, mucous membranes are dry, skin is tenting.)

These are critical thinking skills you are to practice. It is ok if you disagree with a med to be given; give the reason using evidence - a lab or assessment finding. I will see how you are thinking and you will become a safe clinician.

*Remember, if you withhold a med, a phone call to the MD is the next action (tell your instructor this as a way for s/he to validate you understand the communication standard of holding a med.) You must always provide clinical evidence for reasons holding a medicine; always document your reasoning and conversations with the advanced clinician you spoke with. Never call an MD on your own in the clinical setting, ask your RN or instructor for assistance; do not take verbal orders from any clinician at any time while you are a student (unlicensed.)

Laboratory Interpretation Example:

Laboratory test Results Interpretation (WNL/high/low)

Why is the result abnormal in this patient & what is your recommendation for responding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.)

S: Pt is a 39-year-old female with Spina Bifida, Full Code, with allergies to ceftriaxone (rash), penicillin (hives), morphine (rash), latex (dyspnea), and chlorhexadine.

B: Pt. has history of Spina Bifida, sleep apnea, DM II, chronic hypercarbic syndrome, morbid obesity, VP Shunt for hydrocephalus, ileostomy, neurogenic bladder w/ urostomy, chronic paraplegia secondary to spina bifida, wheelchair bound, seizure disorder, chronic UTI, diastolic HF, and viral pneumonia 2 weeks prior to admission.

A: (for assessment) – define the lab, state why the lab is abnormal (use your assessment findings.) R: (for recommendation)- what are you going to assess for and report to the patient care provider. Be patient specific!WBC 11.7: 4/6

10.0: 4/4High A: White blood cells are the body’s defense against

foreign antibodies. This lab would be drawn to assess for infection and inflammation (Nursing Central, 2014.) Pt.’s temperature has been elevated. However, patient’s sputum, and urine came up negative upon analysis. Pt.’s skin and stomas have no signs of breakdown. The patient’s A-line and PICC have been swabbed and sent for analysis. Results will be back tomorrow.

R: Continue to trend WBCs. WBC count and differential counts have increased in the last 24 hours, indicating current antibiotic treatment is possibly not effective. Notify physician. Monitor for s&s of infection- temperature, HR, BP, respirations, breath sounds. (For temp >101 and check with provider if antibiotic should still be administered or should cultures be redrawn.)

You may continue with your next lab, no need to retype Situation and Background.

Medication Interpretation Example:

S: Patient is a 21 y/o male. Patient is here for blunt head trauma and pulmonary aspiration with subsequent malignant intracranial hypertension. He is full code with NKDA and NKFA.

B: Patient has no past medical and pertinent surgical history. He is in the army and was found on the floor of a parking lot.

A: (for assessment) – define what the med does, state why the patient needs the med. R: (for recommendation)- state if you would give or hold med. If you choose to hold the med, state why and that you would alert the patient care provider.Ampicillin/ SulbactamUnasyn

This antibiotic is active against streptococci, pneumococci, and enterococci (Nursing Central, 2014.) FYI: Make sure you state what pathogens this antibiotic is effective against; always check your culture report before administration.

3 gm q 6 hours

A: This medication binds to bacterial cell wall, resulting in cell death; spectrum is broader than that of penicillin (Nursing Central, 2014). The patient’s cultures revealed gram-positive cocci clusters resembling staph, and moderate gram-negative rods in his sputum. In his bronchial, he tested positive for a few gram-positive cocci and many staph aureus. The patient is trying to fight off infection in his body, and particularly his lungs. This antibiotic is active against streptococci, pneumococci, and enterococci (Nursing Central, 2014).

R: I would recommend giving this medication. The patient is positive for cocci and the med acts against streptococci, pneumococci, and enterococci. I would check the temp at least q 1 hour and if temp is >101 - I would consider holding the med and ask provider if cultures should be redrawn because the patient may have resistant organisms to the drug. If the patient experiences diarrhea, I would ask the provider if stool culture is needed to determine if c. diff is positive.

Continue with your next med, no need to retype Situation and Background.

REMEMBER TO INCLUDE PERTINENT ABNORMAL LABS IN YOUR PROBLEM LIST AND PLAN OF CARE (POC). The recommendations you’ve developed for both lab & med sections should be used in your POC.

It is ok for you to recommend increasing or decreasing lab monitoring. It is ok if you disagree with a med to be given. Give the reason you wish to hold a med or change frequency of a lab draw, using evidence such as an assessment finding, your lecture notes, Nursing Central, or your text.

Remember, if you withhold a med, a phone call to the MD is the next action when you become a licensed nurse (state this in your recommendation.) Also, you must provide clinical evidence for reasons holding a medicine; always document your reasoning and conversations with the advanced clinician you spoke with; finish the loop of communication and document.

Laboratory Interpretation

Laboratory test Results Interpretation (WNL/high/low)

Why is the result abnormal in this patient & what is your recommendation for responding to the value? (A: includes what the test measures & hx, assessment findings, etc. pertinent to the test.)

S:

B:

A: (for assessment) – define the lab, state why the lab is abnormal (use your assessment findings.) R: (for recommendation)- what are you going to assess for and report to the patient care provider. Be patient specific!

A:

R: You may continue with your next lab, no need to retype Situation and Background.

A:

R: A:

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Medications (add Additional Pages as needed)

S: Patient is a 21 y/o male. Patient is here for blunt head trauma and pulmonary aspiration with subsequent malignant intracranial hypertension. He is full code with NKDA and NKFA.

B: Patient has no past medical and pertinent surgical history. He is in the army and was found on the floor of a parking lot.

A: (for assessment) – define what the med does, state why the patient needs the med. R: (for recommendation)- state if you would give or hold med. If you choose to hold the med, state why and that you would alert the patient care provider.Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

Generic Name: Trade Name: Therapeutic Class:

Dosage:Safe dose:Frequency:

A:

R:

Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Route:Time:

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

Generic Name: Trade Name: Therapeutic Class: Pharmacologic Class:

Rationale for use:

Expected therapeutic effect:

Action:

Dosage:Safe dose:Frequency:Route:Time:

A:

R:

1. Create a problem list (using NANDA nursing diagnoses) prioritizing 10 simulated patient’s issues you have observed. Additionally, the student will state, using evidence (cited), why they have prioritized the NANDA diagnoses in the order of their choosing. If the prioritization is missing or is incorrect, the instructor will deduct points.

List 10 NANDA approved nursing diagnoses, that you observed and prioritize them. Students may use an “at risk” or “associated condition” NANDAs to create this list. Use an evidence-based rationale (paraphrase when possible and use in-text citations along with an APA reference page).

NANDA RATIONALE for prioritization1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

1. NANDA Nursing Diagnosis: ___________________________________________ Related to: ___________________________________________________

As evidenced by (only use if not “risk for”): _______________________________________________________________________________________________

PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASEPatient-centered goal (s)

Be sure goal is measurable and includes an appropriate time frame.Consider: Short-term goal & long-

term goal(SMART GOAL)

Interventions: Must be written in order of priority. Think about all the things the RN does to help the

patient with this problem. Be specific.

Use a primary source to provide the rational for your specific

nursing intervention. Cite references.

Goal/s met?

2. NANDA Nursing Diagnosis: ___________________________________________ Related to: ___________________________________________________

As evidenced by (only use if not “risk for”): _______________________________________________________________________________________________

PLANNING PHASE IMPLEMENTATION PHASE RATIONALE EVALUATION PHASEPatient-centered goal (s)

Be sure goal is measurable and includes an appropriate time

frame.Consider: Short-term goal &

long-term goal(SMART GOAL)

Interventions: Must be written in order of priority. Think about all the things the RN does to help the

patient with this problem. Be specific.

Use a primary source to provide the rational for your specific

nursing intervention. Cite references.

Goal/s met?