Patient Care Assessment and Concept Map
| Title | Patient Care Assessment and Concept Map |
Directions:
- Complete the following information gathering for the patient you will be caring for at the clinical setting.
- 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):__________________________________________________
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| Medication Profile
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| Medication | Reason for use |
Clinical Concept Map
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Develop a concept map that identifies the following care components for each patient. Use arrows to connect pieces that are interrelated (Revised from SCTC).
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| 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.
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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. |
| Total Points | |||
Revised from Linda Caputi ©, St. Cloud Technical College, and Hennepin Technical College, and Dakota County Technical College
