Title Patient Care Assessment and Concept Map
Directions:
1. Complete the following information gathering for the patient you will be caring for at the clinical setting.
2. Dropbox the Concept Map.
Initials:_________
Age: Gender:
Student Name: ____________________________________Date:_________
Code Status:____________________________
Allergies: ______________________________
Vitals from Visit:
Height: ______________
Last wt: ________ Most current wt:_________
(Note a 3 lb change in a day or a 5 lb change in a week?)
BP ____________ Pulse: _____
O2 sat (as appropriate) __________
Current Abnormal Labs (in last 2 weeks, reason they were drawn [dx/condition], order changes if any) _______________________________________ _______________________________________
_______________________________________
_______________________________________
_______________________________________ Diagnosis (Only current and ongoing)/Surgical dates (if applies): ________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Blood Glucose Time: ______Result: _______ Time: ______Result: _______
Pain: Location: ________________________________________________
Severity: Pain Rating Scale before intervention: ______________________
Interventions (time): ________________________________________________
_________________________________________________________________
Evaluation (time):__________________________________________________
Medication Profile
Medication Reason for use
Clinical Concept Map
Develop a concept map that identifies the following care components for each patient. Use arrows to connect pieces that are interrelated (Revised from SCTC).
Rubric for Concept Map Grading
Criteria
Satisfactory (1 points each)
Needs Improvement (0.5 points each)
Unsatisfactory (0 points each)
1. Assessment Completes assessment page completely Has 2 to 3 areas that need improvement on the Assessment Page Has 4 or more areas that need improvement on the Assessment Page.
2. Nursing Priority Problems Identifies 2 PRIORITY nursing problems Identifies 1 PRIORITY nursing problems Identifies 0 PRIORITY nursing problems
3. Nursing Interventions Lists 2 nursing interventions under each priority nursing problems Lists 1 nursing interventions under each priority nursing problem. Lists 0 nursing intervention under each goal statement
4. Preventing Complications
1. What are you alert for in this patient
2. What are the important assessments to make?
3. What complications may occur?
4. What interventions will prevent complications?
5. What will you do if complications do occur? Answers 4-5/5 questions correctly.
Answers 2-3/5 of the questions correctly Answers 1/5 of the questions correctly.
5. Educational Needs Able to identify 2 or more educational needs for patient Able to identify 1 educational need for patient. Unable to identify educational needs of patient.
6. Reporting to the RN and Changes in Patient Condition Able to identify 2 or more concerns that should be reported to the RN. Able to identify 1 concern that should be reported to the RN. Unable to identify concerns that should be reported to the RN.
7. Cultural, Spiritual, and Psychosocial Concerns Able to identify 2 cultural, spiritual, and psychosocial concerns Able to identify 1 cultural, spiritual, and psychosocial concerns Unable to identify cultural, spiritual, and psychosocial concerns
8. Signs and Symptoms Able to identify 2 signs and symptoms of disease in patient. Able to identify 1 sign and/or symptom of disease in patient. Unable to identify signs and symptoms of disease in patient.
9. Lab value and Diagnostic Tests Able to explain 2 abnormal lab values and/or diagnostic tests and what they mean for this patient. Able to explain 1 abnormal lab values and/or diagnostic tests and what they mean for this patient. Unable to explain abnormal lab values and/or diagnostic tests and what they mean for this patient.
10. Medications Able to identify 2 main medications that are ordered for the patient and the rationale for the medications. Able to identify 1 main medications that is ordered for the patient and the rationale for the medication. Unable to identify the main medications that are ordered for the patient and the rationale for the medications.