NURSE KNOWLEDGE EXCHANGE
PATIENT INFORMATION
Student’s Name:
Beatriz
Date of Care: 10/23/2020
Torres
Patient Initials:
KY
Age/Gender/ Ethnicity:
Height/ Weight (Kg):
Code Status:
Admission Date: Season2/Episode
Unit/ Room Number:
Used5
Post –Operative Day No:
Religious Affiliation:
Medical Background
Chief Complaint on Admission:problems breathing,coughing, wheeze with breathing
x4days
Admitting Medical Diagnosis: What is the reason the patient was admitted?
Current or Working Medical Diagnosis: .chronic condition is reactive airway problems
Significant Medical History (Include all active Medical Diagnoses): chicken pox at age 3
History of Present Illness (In chronological order, describe the patients description of the
events that lead to this admission)
Enter the story of how the patient got to where they are now.
Do not just say, “Pt was admitted to ER for xxxx”
10/23/2020, On the 4th day after experiencing breathing problems, coughing
during the nights waking rest of the family too, and noticing subtle wheezing
with breathing. Medication prescribed Albuterol inhaler and OTC
Loratadine (Claritin) were not helping relief symptoms. Mom states
symptoms occur around these time of the year with allergies. Client is
alert,full oriented. Labored breathing. Wheezes throughout lung fields
noted.
[Type here]
[Type here] Edited by M. Anderson version 2 -7/22/2019
If Pt is on room air note RA. If Pt is on oxygen,
complete appropriate information
ACTIVE ORDERS SHEET
Respiratory Care Modalities
O2 Device: _____________ L/min__________ FiO2 %_________
ETT (Size, cm@lip) _________________ TRACH (TYPE)_______ _______________
If intubated or trached, how many days? ____
_ SAO2___________
Settings: Mode (AC, SIMV, etc.): _ Tidal volume (vT): ______
______
Chest Tube : Y/N Location:
_
FiO2: _______PEEP:
Water seal/Suction
cm
Prescribed Diet : (include NPO status if applicable):
DIET: What diet is your patient currently on? Don’t forget to add textures, liquid
thicknesses, fluid restrictions, etc.
Enteral feeding (if applicable, incl. type- Glucerna, Nutrivent, etc.) If Pt is on tube
feedings be sure to put the formula type, daily calories, rate, etc.
Rate:
Average Residuals
Parenteral nutrition (if applicable, TPN or PPN?):
Rate:
Lipids: Y/N
Rate
Rationale for above:
If your Pt is receiving TPN or PPN complete this section.
Safety Precautions
List all safety precautions here!! Examples: Aspiration, fall, seizure, no BLT
(bending/lifting/twisting), spinal precautions, etc.
IV Fluid
Enter IV fluids here! Example: NS @ 100mL/hr
[Type here]
[Type here] Edited by M. Anderson version 2 -7/22/2019
Enter your Pt’s vital signs here. Since we are not in a
hospital, please use the season/episode as your time
notation.
VITAL SIGNS
[Type here]
If ANY of the vitals are
above or below “normal
limits” ID with a “L” or
“H”
[Type here] Edited by M. Anderson version 2 -7/22/2019
Please refer to the “3-2020 NKE PA Success Tips.docx” file in Canvas
for itemized suggestions/recommendations for this section!
PHYSICAL EXAMINATION SUMMARY SHEET
Instructions: Document your patient’s physical exam findings in the boxes below. Underline all abnormal findings.
Vital SignsVITAL SIGNS Time:
PATIENT INITIAL:
TEMP:
AGE
Temperature
HR:
GENDER
RR:
RACE
BP:
Pulse Rate or Heart
ETHNICITY
SaO2
Rate
CC:
PAIN
ADMITINGRespiratory Rate
DIAGNOSIS
Blood Pressure
Time:
GENERAL SURVEY
Oxygen Saturation
CARDIOVASCULAR
RESPIRATORY
STATUS
Pain Rating
If pt has any pain be STATUS
ACTIVE MEDICAL
Location: sure to note the
DIAGNOSES
Provoking Factors PQRST info
Quality
Radiation
Severity
Timing
PATIENT Implications
If you have ID’d a
for any Abnormal Vital
vital sign that is H
MUSCULOSKELETAL
INTEGUMENTARY
Sign
or L, list the
STATUS
STATUS
potential issues FOR
YOUR PATIENT!
NURSING Implications If you have ID’d a
for any Abnormal Vital
vital sign that is H
Sign
or L, list the what
YOU
the nurse PSYCHOSOCIAL,
URINARY
STATUS
SPIRITUAL AND
needs to do!
CULTURAL
NEEDS
Orders, assessments,
interventions, etc.
[Type here]
Time:
NEUROLOGICAL
STATUS
GASTROINTESTINAL
STATUS
SAFETYPRECAUTION AND
INFECTION CONTOL
OTHERS
[Type here] Edited by M. Anderson version 2 -7/22/2019
E
N
D
O
C
R
I
N
E
S
T
A
T
U
S
Please refer to the “3-2020 NKE PA Success Tips.docx” file in Canvas for itemized
suggestions/recommendations for this section!
[Type here]
[Type here] Edited by M. Anderson version 2 -7/22/2019
Do not forget to provide in-text citations for
your references for this page!
List all medication mentioned in ALL
seasons/episodes!
NKE
MEDICATION LIST
MEDICATION ORDER
(Include Generic Name,
Brand name and complete
order. Include all
scheduled and PRN
medications)
CLASSIFICATION
INDICATIONS
FOR THIS
PATIENT
List the name of
the med (generic
and brand name)
and list the dosage,
time, prn
parameters, etc.
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
SIDE
EFFECT
(at least 3)
ADVERSE
EFFECT
(at least 3)
CONTRAINDICA
TION
(at least 3)
NURSING
CONSIDERATIONS
(Include monitoring ,
nursing interventions and
safety interventions)
PATIENT TEACHING
(Include drug interaction,
food interaction and follow
up care)
Do not forget to list
the actual item to
check and the
parameters you are
checking! DO NOT
just say “check labs”,
“monitor vitals”
Don’t forget to
include all patient
teaching items!! Use
ATI as your #1
source!!
List ALL labs that are mentioned in
ALL seasons/episodes! Use the S/E
you found the lab as the date
NKE
LABORATORY AND DIAGNOSTIC TEST AND INTERPRETATION
DATE
LABORATORY AND
DIAGNOSTIC TEST
Identify what the
test is. Example:
Hgb (not CBP)
PURPOSE OF TEST
(for the patient)
Identify what the
test is testing for.
Do not just state
“to see how much
Hgb the patient
has”. What does
Hgb testing TELL
us?
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
RESULTS
NORMAL
RANGE
(from hospital)
Use the
ranges
provided in
the lab
worksheet
from your
daily docs
SIGNIFICANCE OR IMPLICATION
(What are possible reasons for this lab value?
Are there any medications or procedures you
need to withhold due to this lab value? Is this
a side effect, adverse effect or a complication
of the patient’s disorder?)
Remember this section is
essentially 3 parts: 1) what does
the high or low value mean in
general for ALL patients? 2) How
does this high or low value
connect to your patient? Think
disease process, medication s/e,
or injury. 3) What do YOU as the
nurse need to do? Is there
something else to monitor? Call
the MD? Orders to obtain?
Interventions to implement?
Be sure to list each individual lab on separate lines and address each lab
individually!!
Be sure to identify what items correlate to YOUR patient with an “ * “. Look at the rubric! This is worth ¼ of the points for
this section!!
NKE
PATHOPHYSIOLOGY
(Identify the risk Factors of the condition, Signs and Symptoms of the condition, Diagnostic Tests and laboratory results. Use lines and arrows to show
progression of the disease process. Identify with an * which ones are specific to your patient.
List risk factors
for the disease
process
Weather changes,
pollution,
chemicals. Cats,
pets
Potential
Complication #1
(not able to walk
or exercise)
Potential
Complication #2
(breathing
problems, not
able to go to
school or work)
List the most
common EARLY
small coughs, like
allergy reactions
to the weather
Asthma- inflammatory
disorder of the airways,
episode of wheezing,
breathlessness, chest tightness,
coughing.
Reactive airway disease.
Pearson 2008-2014.
Potential
Complication #3
Asthma attacks
SOB go to the
ER)
COMPLICATIONS
#1 Ineffective airway
#2 Asthma attacks ,ER visit
#3 lung infection
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
List the most common
LATE wheezing,
shortness of breath,
chest tightness,
coughing.
List the diagnostic’s used to
identify the disease process:
Respiratory rate, effort, any
pain, O2Sat, LOC, blood test to
check for infection in the lungs.
Potential
Complication #4
(developing
infection in the
lungs )
3 SIGNS OF COMPLICATIONS
S/S 1-worsening cough, , 2 ineffective 02
perfusion, 3unable to rest/sleep
S/S 1unabe to breath properly, 2medication not
helping, 3triggers
S/S 1cough, 2breathing problems, 3fever
NURSING CARE PLAN
Be sure to identify your #1, 2,
& 3 PRIORITY ID for your
3 care plan pages!
NKE
Instructions: Formulate 3 priority care plans for your patient. Use 2 actual nursing diagnoses and 1 risk nursing diagnosis.
Priority No.
3 PART ACTUAL DIAGNOSIS: Ineffective airway pattern R/T cough x4days AEB adventitious lung sounds(wheezing with
breathing).
Goal
What is your OVERALL goal for your patient? effective airway pattern
Long Term Objective
What is your LONG TERM GOAL for your patient . Client able to breath within normal range without effort
Short Term Objective
What is your SHORT TERM GOAL for your patient. Client will able to rest/sleep tonight.
INTERVENTIONS
RATIONALE
OUTCOME CRITERIA AND EVALUATION
Instructions: Evaluate the Goal, Long Term and
Provide appropriate citation from scientific sources from the
Independent
last 5 years
Evaluation of the Goal:
( x) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: client able to breath with no
effort
Assessment/ Monitoring and Evaluation
Maintain open airway
RR normal range
No more wheezing sounds
Positioning
High folwer’s
Short Term Objective. Provide evidence of the
patient meeting or not meeting the goal
Pearson 2018-2014
Diet
High calories
Rest and Activity
Exercise as tolerated
Preventative/ Promotive
Health Teaching
Teach client to know the early signs and symptoms
Teach mom to recognized breathing problems
Exercise as tolerated.
Avoid cats/pets inside the house.
Avoid allergic triggers
Dependent
Do you need an order for what you are wanting to do
above? Be specific!!NO
Follow up visit in a week to check lung sounds and breathing
pattern.
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
Evaluation of the Long Term Objective:
( x ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: clients has not experiencing any
cough or breathing problems
Evaluation of the Short Term Objective:
(x ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: client able to rest/sleep during
night without coughing or waking up the
family
NKE
Collaborative
Who do you need on your team to help your patient?
See Care Plan #1 above for instructions
NURSING CARE PLAN
Priority No.2
3 PART ACTUAL DIAGNOSIS: Health-seeking behaviors by mom R/T (decrease coungh/adventious lung sounds to kelsy) AEB
(mom expressed desired to learn/change house environment to reduced triggers facts.
Goal
What is your OVERALL goal for your patient? Prevent allergic reaction/ adventious lung sounds
Long Term Objective
What is your LONG TERM GOAL for your patient (get rid of any triggers)
Short Term Objective
What is your SHORT TERM GOAL for your patient (have the client with no allergic reactions/ breathing problems)
INTERVENTIONS
RATIONALE
OUTCOME CRITERIA AND EVALUATION
Instructions: Evaluate the Goal, Long Term and
Provide appropriate citation from scientific sources from the
Independent
last 5 years
Short Term Objective. Provide evidence of the
patient meeting or not meeting the goal
Evaluation of the Goal:
( x) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: client verbalize able to sleep
without coughing
No tightness chest
Assessment/ Monitoring and Evaluation
Ask mom about pets/chemical at home
Teach about pollution and allergic reactions
Take rescue medication when needed
Positioning
Sitting up
Diet
Rest and Activity good sleeping pattern
Preventative/ Promotive exercise as tolerated
Avoid stress
Hand washing
Pearson 2018-2014
Evaluation of the Long Term Objective:
(x ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: no allergic reaction
No cats at home
Health Teaching eat high proteins, high calories
Dependent
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
Evaluation of the Short Term Objective:
( x ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence: no cats/pets at home.
Client able to sleep. Able to go to school
NKE
Collaborative
See Care Plan #1 above for instructions
NURSING CARE PLAN
NANDA RISK FOR NDX (NANDA RISK FOR NURSING DIAGNOSIS) R/T (related to)
Priority No.
***REMEMBER – NO AEB in RISK FOR NDX or it exists!!!
Goal
What is your OVERALL goal for your patient?
Long Term Objective
What is your LONG TERM GOAL for your patient (Use SMART goal formatting and do not exceed 7 days)
Short Term Objective
What is your SHORT TERM GOAL for your patient (Use SMART goal formatting and do not exceed your 12 hr shift)
INTERVENTIONS
RATIONALE
OUTCOME CRITERIA AND EVALUATION
Instructions: Evaluate the Goal, Long Term and
Provide
appropriate
citation
from
scientific
sources
from
the
Independent
2 PART RISK DIAGNOSIS:
last 5 years
Assessment/ Monitoring and Evaluation
Positioning
Short Term Objective. Provide evidence of the
patient meeting or not meeting the goal
Evaluation of the Goal:
( ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence:
Diet
Rest and Activity
Preventative/ Promotive
Evaluation of the Long Term Objective:
( ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence:
Health Teaching
Dependent
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
Evaluation of the Short Term Objective:
( ) Goal Met
( ) Goal Partially Met
( ) Goal Not Met
Evidence:
NKE
Collaborative
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
Use the Season/Episode for the
date/time for your nursing note info
source PROGRESS NOTES
DATE
NOTES
See “Nursing Notes Success Tips” in Canvas for instructions on
how to write a proper DAR formatted Nursing Note.
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
NKE
NKE
REFERENCES
Identify all references used to complete this paper. References must be within the last 5 years.
Include the proper citation of references used using APA format. Be prepared for the references to
be validated.
DO NOT FORGET TO PROVIDE APA FORMATTED REFERENCES FOR ALL IN-TEXT
CITATIONS USED IN THIS DOCUMENT.
REMINDER THE FOLLOWING SECTIONS MUST HAVE IN-TEXT CITATIONS:
 YOUR MEDICATION PAGES
 LAB PAGES
 CARE PLAN PAGES

ALL UTILIZE EVIDENCE BASED PRACTICE CITATIONS/REFERENCES THAT ARE LESS
THAN 5 YEARS OLD AND ARE SOURCED FROM A NURSING/MEDICAL/SCIENTIFIC
SOURCE!
LAST TIP FOR SUCCESS – READ YOUR RUBRIC!! EACH RUBRIC
SECTION IS CORRELATED TO EACH SECTION OF YOUR NKE
DOCUMENT!! FOCUS ON THE 4 POINT COLUMN!
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019
NKE
Drafted and revised by M.Anderson and Prof. G. Case 12/30/2019