Patient Assessment (NR 226 RUA)

STUDENT: ____________________________________ Date of Care: _01-27-20______________

Client Initials: ___V. J_______ Age: _____65_____ Gender: ___F_______

Resuscitation Status ____Full Code_____ Allergies______NKA________________

Reason for Admission: ____Long _Term Care______________________________________________

Medical Diagnoses_ HTN, Peripheral Vascular Disease Unspecified, Hemiplegia and Hemiparesis following Cerebral Infarction Generalized Muscle Weakness, ____________________________________________________________________________________

______________________________________________________________________________________________________

__

Surgeries/Procedures and Dates: ____________________________________________________________________________

Past medical history________________________________________________________________________________________

________________________________________________________________________________________________________

Current Orders:

Diet No Added Salt (NAS), Regular texture, (Thin) consistency, for Heart Healthy Diet; Low Fat, Low Cholesterol related to Essential (Primary)Hypertension__________________________ Activity________________________________

Intake ___________________ Output_________________ Accu Cheks______________________________

Vital signs_______________________________________________________________________________________________

Drsg changes/wound care_No wounds, no dressing changes____________________________________________________

Foley__None_________________________ NG/G-tube/PEG?PEJ_______None____________________________________

IV ___None__________________________________________ Reason for IV_____None_____________________________

Other orders:

______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

______________________________________________________________________________________________________

Most recent Imaging Findings: (CXR? CT? MRI?)

Type of Imaging (X-Ray, CT, MRI, etc)

Body Area Imaged

Reason for testing and results of test

Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)

Date

Lab Test

Results

Norms

Comments

Other recent, significant procedures or tests (EKG, etc)

Date

Test

Reason for testing and results of test

Review of pathophysiology:

9

You may copy and paste these tables onto the next sheet if you have more medications

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Acetaminophen Tablet (Tylenol)

325-650mg

In patients hypersensitive to this drug. Stevens-Johnson syndrome, Acute Renal Failure Pts

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Analgesics

Give 650mg

Fatigue, insomnia, nausea, vomiting, diarrhea, rash muscle spasm

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt taking this med as needed for generalized pain

PO every 6 hours as needed

Many OTC and prescription products contain acetaminophen, be aware when calculating total daily dosage. Contact MD if s/s of liver damage occur.

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Atorvastatin Calcium Tablet (Lipitor)

10 – 80 mg

In patients with active liver disease, Renal failure caused by Rhabdomyolysis, acute myopathy

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Antilipemic/HMG-CoA reductase

40mg

Insomnia, nasopharyngitis, myalgia, extremity pain, muscle pain

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt has high cholesterol levels

Give 1 tablet PO one time a day

Pt should follow standard cholesterol-lowering diet before and during therapy. Obtain baseline LFT and lipid levels and during therapy and 6 -12 weeks after treatment started

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Hydralazine HCL Tablet

10-100mg

With pts hypersensitive to the drug, with CAD or Mitral Valvular Rheumatic Heart disease.

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Antihypertensive

10 mg as needed

Palpitations, tachycardia, orthostatic hypotension, edema, flushing

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt is hypertensive

PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105

Monitor BP, pulse rate, and body weight frequently, Elderly pts may be more sensitive to low blood pressure effects

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Lisinopril (Zestril)

Tablet

2.

5-40mg

Pt with history of angioedema, hypersensitive to ACE inhibitor,

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Antihypertensive/ACE inhibitor

40mg

Dizziness, headache, nasal congestion, dyspepsia, impotence, orthostatic hypotension, hypotension

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt is hypertensive

PO, give 1 tablet one time a day every 6 hours as needed for Per vital Sign Parameter related to Essential (Primary) Hypertension for SBP>180, DBP>105

Monitor BP frequently, monitor glucose, electrolyte, and lipid levels during therapy, discontinue use if jaundice and elevated liver enzyme levels occur. Monitor for angioedema of face, tongue or larynx

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Famotidine Tablet (Pepcid)

Tablet 10-40mg

Hypersensitive to drug or its derivative, QT-interval prolongation and torsades de pointes

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Antiulcer/H2-receptor antagonists

20mg

Headache, dizziness, irritability, constipation, diarrhea, vomiting

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt has GERD

PO, give 1 tablet one time a day for heartburn

Monitor pt for abdominal pain, assess for blood in stool, monitor pt with renal dysfunction for QT-interval prolongation

Brand Name and Generic Name

Normal Dosage Ranges

Contraindications

Plavix Tablet (Clopidogrel Bisulfate)

Tablet 75-300mg

History of sensitivity to the drug, inn pts with hematologic reaction and intercranial hemorrhage

Pharmacotherapeutic Class

Dosage Ordered

Adverse Reactions

Antiplatelet/Platelet aggregation inhibitors

75 mg

Confusion, abdominal pain, epistaxis, ulcers, myalgia, Stevens-Johnson syndrome

Why is patient receiving this med? (Can list related diagnosis, symptom, or need)

Route and Frequency

Nursing Considerations and Teaching

Pt has peripheral vascular disease

PO, give 1 tablet one time a day for CVA

Teach pt to avoid grapefruit juice and drug may be given without food. Advise pt that bleeding may take longer than usual to stop and to stop any activities where trauma or bleeding may occur. Notify MD if bruising or bleeding occurs.

Medications

Routine Findings

Patient Variations/Abnormals

Skin –

Head and neck –

Respiratory –

Cardiovascular

Abdomen –
.

Bowel continence? Last BM? Bowel Plan?

Neurological

Musculoskeletal – .

Genitourinary –

Urinary continence? Toileting plan?

Nursing Diagnosis #1: Imbalanced Nutrition more than body requirements

Related to (

RT

): intake of nutrients that exceeds metabolic needs

As evident by (

AEB

): body weight (30% over ideal for height)

Planning/Desired Outcome(s):

Pt will progressively lose weight/ pt will lose at least 1 pound per week until a goal of 4 pounds per month is reached

Pt will eat healthy meals with fruits for snacks each day/ pt will consume 1500kcal/day

Pt will show no sign of excess weight / Physical assessment findings and lab values will be within normal ranges

Implementation/Nursing intervention(s):

Rationale

Evaluation/Patient Response

Nurse will coordinate care with PCP, Dietitian, PT and family

Coordination of nutritional care helps for a more successful outcome

Individulaized food and menue according to pt’s preferences

Pt will be encouraged to eat by incorporating her food preferences

Nursing Diagnosis #2:

Related to (RT):

As evident by (AEB):

Planning/Desired Outcome(s):

Implementation/Nursing intervention(s):

Rationale

Evaluation/Patient Response

Nursing Diagnosis #3:

Related to (RT):

As evident by (AEB):

Planning/Desired Outcome(s):

Implementation/Nursing intervention(s):

Rationale

Evaluation/Patient Response

Medical Diagnoses:

Key Assessments:

1.

2.

3.

4.

5.

Problem#_________

ND:

RT

AEB
Problem#_________
ND:

RT

AEB

Problem#_________
ND:

RT

AEB

Problem#_________
ND:

RT

AEB
Problem#_________
ND:

RT

AEB

Linkages Legend

NR226 Fundamentals: Patient Care

REQUIRED UNIFORM ASSIGNMENT: CLINICAL CONCEPT MAP

PURPOSE
This assignment is designed to extend the learner’s use of concept mapping as a tool for
clinical care planning. The nursing process continues to provide the foundation for
organizing information and thought, whereas the mapping becomes the process for
intentional critical thinking and clinical reasoning.

COURSE OUTCOMES THIS ASSIGNMENT ENABLES THE STUDENT TO MEET THE FOLLOWING COURSE OUTCOMES.
CO 1: Demonstrate the nursing process while providing basic care to individuals and families reflecting
different stages of the life span in the extended care, acute care, and community-based settings. (PO #1)
CO3: Demonstrate communication skills necessary for interaction with other health team members and
for providing basic nursing care to individuals and families. (PO #3)
CO4: Incorporate critical thinking skills into clinical nursing practice. (PO #4)

DUE DATE
Refer to Course Calendar for details. The Late Assignment Policy applies to this assignment.

TOTAL POINTS POSSIBLE
100

REQUIREMENTS

Choose an individual for whom you perform nursing care in the clinical setting. After
performing a complete assessment of the person, create a concept map. You will use the
nursing process to map your findings, create and prioritize nursing diagnoses, plan
interventions, and evaluate outcomes of those interventions. Use at least two published
nursing references (other than textbooks) to support your plan of care.

In addition to the concept map and in relationship to it, you will submit a one‐page
reflective pape r that addresses communication and safety and infection control. Based on
your clinical experience with the person for whom you provided care, you will reflect on
specific elements of communication used during your interaction. Finally, you will discuss
issues of safety and infection control related to the care of the person.

Refer to the grading rubric for the detailed expectations regarding content.

NR226 Fundamentals: Patient Care

NR226 Concept Map Guideline x Revised 11/01/17 wbs 2

PREPARING THE ASSIGNMENT
To prepare the concept map, you may use any software of your choosing. Your textbooks and the Internet may

offer access to simple and free concept map creation tools. Although you may select any format for the

assignment, all aspects of the assignment must be included, and the parts of the map must be clearly labeled.

There is also a concept map template located in the Unit 1 assignment page of this cour se. Be sure to check with

your faculty on the preferred format/template.

NR226 Fundamentals: Patient Care

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DIRECTIONS AND ASSIGNMENT CRITERIA

Assign me nt

Criteria

Points % Descript io n

Individual’s
Information

10 10% Include age, medical diagnoses, and brief
pathophysiology review.

Assessment Data 15 15% Include all assessment data, not simply information that
supports the selected nursing diagnoses.

Nursing Diagnoses 15 15% Select three nursing diagnoses. At least one must be an
actual problem, and one must address a psychosocial need.

Linkages Between
and Among
Diagnoses

5 5% Concept map demonstrates relationship within and between
the nursing diagnoses.

Planning 15 15% Prioritize the diagnoses to reflect needs of the individual. Set
realistic outcome goals.

Implementation 15 15% Interventions are appropriate and will help individual
achieve stated outcome goals.

Evaluation of
Outcomes

5 5% Evaluate the individual outcomes that were developed
during planning. Were outcomes met or not? (It is OK to not
meet outcomes, just explain why and what adjustments will
be made.) Why were outcomes met? Do not simply say
“Outcome met.”

Reflection:
Communication

8 8% Therapeutic and nontherapeutic, verbal and nonverbal
communication are analyzed; improvement measures are
addressed.

Reflection: Safety 8 8% Safety and infection control are explored.

Writing Mechanics
and APA

4 4% Proper APA format, grammar, writing mechanics and spelling

Total 100 100%

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GRADING RUBRIC

Assignment
Criteria

Outstanding or Highest Level of
Performance

A (92–100%)

Very Good or High Level of
Performance

B (84–91%)

Competent or Satisfactory Level
of Performance

C (76–83%)

Poor, Failing or Unsatisfactory
Level of Performance

F (0–75%)

Individual’s
Information
(10 points)

Incl udes all bulleted points

 Age
 Medi cal

diagnoses

AND

Informati on in bulleted points is
correct.

Revi ew of pathophysiology is
thorough, accurate, and brief.

10 points

Incl udes two bulleted points
 Age
 Medi cal

diagnoses
AND
Informati on in bulleted points is
correct.

Revi ew of pathophysiology is
thorough and accurate, though
not bri ef.

9 points

Incl udes one of the bul leted
poi nts

 Age
 Medi cal

diagnoses
AND

Informati on in bulleted points is
correct.

Revi ew of pathophysiology is
accurate, though not thorough or
bri ef.

8 points

Incl udes none of the
bul l eted points

 Age
 Medi cal

diagnoses
OR

Informati on in one or
more bul l eted points i s
i ncorrect.

Revi ew of pathophysiology is
accurate, though not thorough
or bri ef.

0–7 points

Assessment
Data

(15 points)

92–100% of assessment data
col l ected i n the cl inical setti ng are
reported wi thin concept map.

14–1

5 points

84–91% of assessment data
col l ected i n the cl inical setti ng are
reported wi thin concept map.

1

3 points

76‐83% of assessment data
col l ected i n the cl inical setti ng are
reported wi thin concept map.

1

2 points

75% or less of as s essment data
col l ected i n the cl inical setti ng
are reported wi thin concept
map.

0–11 points

Nursing
Diagnoses

Three total di agnoses are
accuratel y mapped.

 At l eas t one di agnosis i s an actual
probl em.
 At l eas t one di agnosis is a

ps ychosocial issue.

14–15 points

Two total di agnoses are
accuratel y mapped.

 At l eas t one di agnosis i s an actual
probl em.
 At l eas t one di agnosis is a

ps ychosocial issue.
13 points

One di agnosis is accurately mapped.
 Mapped di agnosis i s ei ther an

actual problem or a
ps ychosocial issue.

12 points

No di agnoses are mapped.
OR
One to three total di agnoses are
mapped i ncompletel y and/or
do not i ncl ude an actual
probl em or psychosocial issue.

0–11 points

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NR226 Concept Map Guideline x 11/01/17 wbs 5

(15 points
total; 3
required
worth 5 points
each)

Linkages Between
and Among
Diagnoses

(5 points)

 Concept map demonstrates
rel ationship within and
between the nurs i ng
di agnoses.

AND
 Legend i s i ncluded.

5 points

This category is either complete and receives full credit or is
incomplete and receives no credit.

 Concept map does not
demons trate rel ationship
wi thi n and between the
nurs ing diagnoses.

OR
 Legend i s not i ncluded.

0 point

Planning
(15 points)

 Diagnoses prioritized to
reflect needs of the
individual

AND

 Outcomes clearly defined

14–15 points

 Diagnoses prioritized in a
general manner not
reflecting the needs of one
individual

AND
 Outcomes clearly defined

13 points
 Diagnoses prioritized in a
general manner not
reflecting the needs of one
individual

OR
 Outcomes clearly defined

12 points

 Diagnoses not prioritized

AND
 Outcomes not defined

or unclear
0–11 points

Implementation
(15 points)

 Interventi ons are
appropriate wi th supported
rati onales .

 Interventi ons will hel p
i ndi vidual achieve
s tated outcome goals.

14‐15 points

 Interventi ons are mos tly
appropriate wi th
s upported rationales.

 Interventi ons may hel p
i ndi vidual achieve
s tated
outcome goals.

13 points

 Interventi ons are
appropriate wi th some
rati onales present.

 Interventi ons may hel p
i ndi vidual achieve
s tated outcome goals.

12 points

 Interventi ons are not
appropriate and/or
rati onales are not provided.

 Interventi ons will not
hel p i ndividual achieve
s tated
outcome goals.

0–11 points

Evaluation of
Outcomes
(5 points)

 Outcome attainment
thoroughly
eval uated

 Evi dence provided
s trongly s upports
eval uation of

 Outcome attainment
parti ally evaluated

 Evi dence provided
moderatel y supports
eval uation of
outcome s tatus

 Outcome attainment
mi ni mally evaluated

 Evi dence provided
weakl y s upports
eval uation of
outcome s tatus

 Outcome attainment NOT
eval uated OR

 Evi dence provided does not
s upport evaluation of
outcome
s tatus OR

NR226 Fundamentals: Patient Care

NR226 Concept Map Guideline x 11/01/17 wbs 6

outcome s tatus
 Pl an updated for

thos e outcomes not
met

5 points

 Pl an updated for
thos e outcomes not
met

4 points

 Pl an updated for
thos e outcomes not
met

3 points

 Pl an not updated for
thos e outcomes not met

0–2 points

Reflection:
Communication

(8 points)

Al l poi nts addressed i n paper
 Therapeutic

and
nontherapeutic
communi cation analyzed.

 Verbal and nonverbal
communi cation
analyzed.

 Areas for i mprovement i n
own communi cation patterns
i denti fied

 Improvement plan outlined

8 points

Three poi nts addressed i n paper
 Therapeutic

and
nontherapeutic
communi cation analyzed

 Verbal and nonverbal
communi cation
analyzed

 Areas for i mprovement i n
own communi cation patterns
i denti fied

 Improvement plan outlined

6 points

Two poi nts addres s ed i n
paper

 Therapeutic
and
nontherapeutic
communi cation analyzed.

 Verbal and nonverbal
communi cation
analyzed.
 Areas for i mprovement i n
own communi cation patterns
i denti fied

 Improvement plan outlined
4 points

Zero or one poi nt addressed
i n paper
 Therapeutic and

nontherapeutic
communi cation
analyzed.

 Verbal and nonverbal
communi cation
analyzed.
 Areas for i mprovement i n
own communi cation patterns
i denti fied
 Improvement plan outlined

0–3 points

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Reflection:
Safety

(8 points)

 Identi fies s afety
hazards present
bas ed on i ndividual’s
condi tion and
nurs ing diagnoses
s el ected

AND
 Identi fies i nfection

control i s s ues
pres ent bas ed on

i ndi vi dual ’s
condi ti on and

nurs ing diagnoses
s el ected
AND

 Refl ects on ways in
whi ch the nurse can
decrease thes e risks
to i ndividuals i n thei r
care

8 points

 Identi fies s afety
hazards present
bas ed on i ndividual’s
condi tion and
nurs ing diagnoses
s el ected

OR
 Identi fies i nfection

control i s s ues
pres ent bas ed on
i ndi vi dual ’s
condi ti on and
nurs ing diagnoses
s el ected
AND

 Refl ects on ways in
whi ch the nurse can
decrease thes e risks
to i ndividuals i n thei r
care

6 points

 Identi fies s afety
hazards present
bas ed on i ndividual’s
condi tion and
nurs ing diagnoses
s el ected

OR
 Identi fi es
i nfecti on control

i s s ues pres ent
bas ed on

i ndi vi dual ’s
condi ti on and

nurs ing diagnoses
s el ected
OR

 Refl ects on ways in
whi ch the nurse can
decrease thes e risks
to i ndividuals i n thei r
care

4 points

 Does NOT i denti fy
s afety hazards and
i nfecti on control
i s s ues based on
i ndi vidual’s condition
and nursing
di agnoses s elected

AND
 Does NOT refl ect

on ways i n which
the nurs e can
decrease thes e
ri s ks to i ndividuals
i n thei r care

0–3 points

Writing style,
APA format,
grammar,
spelling,
mechanics

(4 points)

Al l criterion i tems are met:
 Fl ow of i deas logical and

eas y to fol low

 Ideas are presented clearly
 APA formatti ng free of

errors
 Incl udes reference l ist and

i n-text ci tations
 Spel l ing, grammar, and

mechani cs are free of
errors

4 points

Di d not meet one (1) of the
cri terion i tems:

 Fl ow of i deas logical and
eas y to fol low

 Ideas are presented clearly
 APA formatti ng free of
errors
 Incl udes reference l ist and
i n-text ci tations
 Spel l ing, grammar, and

mechani cs are free of
errors

3 points

Di d not meet two (2) of the
cri terion i tems:

 Fl ow of i deas logical and
eas y to fol low
 Ideas are presented clearly
 APA formatti ng free of
errors
 Incl udes reference l ist and
i n-text ci tations
 Spel l ing, grammar, and

mechanics are free of errors

2 points

Di d not meet three (3) or more of
the cri terion i tems:

 Fl ow of i deas logical and
eas y to fol low
 Ideas are presented clearly
 APA formatti ng free of
errors
 Incl udes reference l ist and
i n-text ci tations
 Spel l ing, grammar, and

mechani cs are free of
errors

1 point

NR226 Fundamentals: Patient Care

NR226 Concept Map Guideline x 11/01/17 wbs 8

Total Points Possible 100 points

NR226 Fundamentals: Patient Care

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