Title
Patient Care Assessment and Concept Map
Author
Name or
School
Hennepin Technical College: Assessment
St. Cloud Technical College: Concept Map
Linda Caputi: Preventing Complications
Dakota County Technical College: Time Line
Put X in box to correspond
Put X in box to correspond
Knowledge/Practice/Ethical
with the SLO (s)
with the Competency (s)
Comportment
K
P
E
Patient Relationship
x Communication Skills
Centered Care
Nursing Process
x
x
Learning Needs
Informatics/Technology
Documentation
Informatics
Nursing
X Prioritization
x
x
Judgment/Evidence
Nursing Judgment
x
x
Based care
Student
Learning
Outcome(s)
Professional Identify and
behaviors
Professionalism
Ethical/Legal
Quality Improvement
Patient Care Concerns
Systems
Patient Complications
Safe Nursing
Communication
Conflict Recognition
Managing Care of the
Individual Patient
Assign/Monitor
Safety
x
Teamwork and
Collaboration
Managing Care of the
Individual Patient
Where should this assignment be used:
Classroom
Clinical Setting
Independent Study
Online/Web Based
Skills Lab
Simulation
Patient Care Assignment
Patient Care
The assignments are
related to the student
while providing patient
care in the clinical setting.
Example: Concept
mapping care for one or
multiple patients.
x
x
x
x
x
x
Revised from Linda Caputi © (What type of assignment is this?)
Non Patient Care Assignments
Thinking Focused
Patient Focused
Systems Focused
Assignments encourages
The student focuses on
Assignments help the student
critical thinking and clinical
specific aspects of
understand the clinical world, the
reasoning and teaches
patient care such as
nurse’s work therein, and the effect
students to think like a
safety, falls, diabetes,
of the system on the nurse and the
nurse.
other diseases, etc.
patient.
Example: How the system
completes medication
administration from order to
delivery to patient.
x
Assignment: Patient Care Assessment and Concept Map
Competencies measured by this assignment:
Nursing Judgment/ - PRIORITIZATION OF CARE:
Describe (K), demonstrate (P), and value (E) the ability to prioritize care in delivering quality, patient centered nursing care
across the lifespan.
Nursing Judgment/Evidence Based Care- NURSING JUDGMENT COMPETENCY:
Identify (K), use (P), and appreciate (E) evidence based care when conducting a focused assessment, choosing nursing
interventions within a plan of care, monitoring, and reporting changes in the individualized patient's condition across the
lifespan.
PATIENT/RELATIONSHIP CENTERED CARE - NURSING PROCESS COMPETENCY:
Describe (K), utilize (P), and value (E) the nursing process when participating with other health providers in the development
and modification of a plan of care for patients across the lifespan and in various health care settings.
Safety- PATIENT COMPLICATIONS:
Identify (K), implement actions (P), and recognize (E) one's responsibility to detect and respond to actual/potential patient
complications and report changes to the appropriate health care provider.
Safety- SAFE NURSING PRACTICE:
Explain (K), demonstrate (P), and value (E) safe nursing practice and the relationship between national safety campaigns and
implementation in practice settings.
Directions:
1.
Complete the following information gathering for the patient you will be caring for at the
clinical setting.
2. Complete the Concept Map and present at Post-Clinicals for grading.
3. You will be graded in post clinicals with the rubric attached.
Room #:___________ Initials:_________
Age:
Gender:
Code Status:____________________________
Allergies: ______________________________
Transfer from bed_______________________
Mobility on unit:________________________
(#assist/device)
Diet: __________________________________
Takes meds: Whole /Crush /Thickened /NPO
Bowel/Bladder status:____________________
Last wt: ________ Most current wt:_________
(Note a 3 lb change in a day or a 5 lb change in a
week?)
Intake: _____________% _______________ml
(Did they get > 500 ml in a
shift?)
Output: _________ This shift’s BM: _________
(Has it been 2-3 days without a
BM?)
Date of BM before this shift: _____________
Current Abnormal Labs (in last 2 weeks, reason they
were drawn [dx/condition], order changes if any)
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Student Name: ____________________________________Date:_________
Diagnosis (Only current and ongoing)/Surgical dates (if applies): ________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Blood Glucose Time: ______Result: _______
(This shift only)
Time: ______Result: _______
Vital Signs: This shift’s RR: _______ T: _______ O2 Sats: _____________
This shift BP: ______________
This shift’s Apical Pulse: ___________
Baseline BP: _______________________ Baseline Apical Pulse:
_________________
Heart rate/rhythm: ________________________
Pain: Location: ________________________________________________
Severity: Pain Rating Scale before intervention: ______________________
Interventions (time): ________________________________________________
_________________________________________________________________
Evaluation (time):__________________________________________________
Lung Sounds:_______________________________________________________
O2: Device and Flow Rate__________________________________________
Intervention: ______________________________________________________
Evaluation: _______________________________________________________
Abdomen/BS: __________________________________________________
Pulses: (R):Radial _______ /Pedal _______ (L) : Radial_______ /Pedal _______
Edema (location): _______________________________________________
Capillary Refill: __________________________Skin:________________________
Neurological/Musculoskeletal: Activity/Ambulation____________________
Hand Grasps: R__________L______________Pedal Pushes: R_________L_______
Tingling/numbness/weakness location:
________________________________
Treatments and Medications
Plan and Prioritize
Date:
Patient Initials:
Patient Initials:
1st hour:
Time:
2nd hour:
Time:
3rd hour:
Time:
4th hour:
Time:
5th hour:
Time:
6th hour:
Time:
7th hour:
Time:
Report Taken:
LOC: Alert/Drowsy/Lethargic/Unresponsive: ____________ Orientation_________
1st hour:
Time:
2nd hour:
Time:
3rd hour:
Time:
4th hour:
Time:
5th hour:
Time:
6th hour:
Time:
7th hour:
Time:
Pt. Educational Needs:
1.
2.
Changes in Condition during shift:
Report Given:
VS:
I & O:
Pain:
Behavior:
Treatment:
Nurse initials:_______
Date:
Date/Time
Abnormals:
Nursing Notes (current date/time you are writing note, do not leave note without signature and title)
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).
Safety: Potential Complications:
1. What are you alert for in this patient?
2. What are the important assessments to make?
Priority Problem
or Nursing Diagnosis
Psychosocial
concerns/interventions
Priority Problem or
Nursing Diagnosis
3. What complications may occur?
4. What interventions will prevent
complications?
5. What will you do if the complications occur?
Intervention
Interventions
Linda Caputi © 2010
Pathophysiology
Primary/secondary
diagnosis
Things to Report to the RN:
Cultural/Spiritual/
Developmental Concerns
Signs and symptoms of
diagnosis (* those seen
in your patient)
LABS: 2 abnormal lab values
and/or diagnostic tests and what
they mean for this patient.
MEDS: Identify the 2 main medications
that are ordered for the patient and the
rationale for the medications.
Criteria
Rubric for Concept Map Grading
Satisfactory (__points each)
Needs Improvement (__ points each)
Unsatisfactory (__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.
Charting
Able to chart with minimal cues.
Able to chart but needs occasional cues
Unable to chart without multiple cues
3.
Concept Map
Complete and neat
Missing 1 or more areas.
4.
Nursing Priority Problems
Identifies 2 PRIORITY nursing problems
Identifies 1 PRIORITY nursing problems
Unable to read
Missing 2 or more areas.
Identifies 0 PRIORITY nursing problems
5.
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
Answers 4-5/5 questions correctly.
Answers 2-3/5 of the questions
correctly
Answers 1/5 of the questions correctly.
Able to identify 2 or more educational
needs for patient
Able to identify 2 or more concerns that
should be reported to the RN.
Able to identify 1 educational need for
patient.
Able to identify 1 concern that should
be reported to the RN.
Unable to identify educational needs of
patient.
Unable to identify concerns that should
be reported to the RN.
Able to identify 2 cultural, spiritual, and
psychosocial concerns
Able to identify 2 signs and symptoms of
disease in patient.
Able to explain 2 abnormal lab values
and/or diagnostic tests and what they
mean for this patient.
Able to identify 2 main medications that
are ordered for the patient and the
rationale for the medications.
Able to identify 1 cultural, spiritual, and
psychosocial concerns
Able to identify 1 sign and/or symptom
of disease in patient.
Able to explain 1 abnormal lab values
and/or diagnostic tests and what they
mean for this patient.
Able to identify 1 main medications
that is ordered for the patient and the
rationale for the medication.
Unable to identify cultural, spiritual,
and psychosocial concerns
Unable to identify signs and symptoms
of disease in patient.
Unable to explain abnormal lab values
and/or diagnostic tests and what they
mean for this patient.
Unable to identify the main
medications that are ordered for the
patient and the rationale for the
medications.
6. 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?
7. Educational Needs
8.
Reporting to the RN and Changes in
Patient Condition
9. Cultural, Spiritual, and Psychosocial
Concerns
10. Signs and Symptoms
11. Lab value and Diagnostic Tests
12. Medications
Total Points
Revised from Linda Caputi ©, St. Cloud Technical College, and Hennepin Technical College, and Dakota County Technical College