NURS481 Miami Dade College Concept Map ICU and Discharge Planning Paper Concept Map for a patient in ICU, the patient information is going to be provided. Concept Map
Student Name:
Instructor:
Erickson’s Developmental Stage Related to pt. & Cite
References (1)
Patient Education (In Pt.) & Discharge Planning (home needs)
History of Present Illness (HPI), Pathophysiology of Admitting Dx
(Cite References) Medical, Surgical, Social History (1).
Medical History
Cultural considerations, ethnicity, occupation, religion,
family support, insurance. (1) (14)
Socioeconomic/Cultural/Spiritual Orientation &
Psychosocial Considerations/Concerns, to include
the following Social Determinants of Health
❋Economic Stability ❋ Education
❋Social and Community Context ❋ Health and Health Care
❋ Neighborhood and Built Environment
Diagnostic Test/ Lab Results with dates
and Normal Ranges (3)
Test
Norms
Date
Current
Value
Patient Information
Chief Complaint
(1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
Admitting Diagnosis
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
RT
Freq.
MOA
RN
Considerations
Onset/Peak
/Duration
(Insulin)
Surgical History
Social History
Priority nursing diagnosis #1
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Nutrition/Hydration
(8)
GI (9)
GU (10)
Rest/ Exercise (11)
Outcome/Goal #1
Outcome/Goal #2
Integumentary (12)
Endocrine (13)
Psychosocial (14)
Misc. (Ht/Wt)
Interventions # 2
Interventions #1
Assessment/ Evaluation #2
Assessment/ Evaluation #1
PC Outcomes/Goal
Potential Complications/ at
risk for
Priority nursing diagnosis #2
PC Interventions
PC Evaluation Plan
Name: NURS 481L Concept Map Rubric
Exit
•
•
G rid View
List View
M eets or Exceeds Expectations
M ostly Meets Expectations
A pproach
1 . Pathopysiology for
a dmitting d iagnosis, S/S,
D iagnostic test and proposed
t reatment
Points:
Points:
Points:
9.9 (11.00%)
7.524 (8.36%)
4.95 (5
Pathophysiology is explained in
complete detail with accurate and
in-depth understanding of chief
complaint and presenting
signs/symptoms supported by
diagnostic test and proposed
treatment plan; APA
Pathophysiology is explained in
some detail with some
understanding of chief complaint
and presenting signs/symptoms
somewhat supported by
diagnostic test and understanding
to proposed treatment plan
Pathophy
vaguely w
understan
and prese
vaguely s
tests and
proposed
2 . History of other health
p roblems, h ospitalizations and
s urgeries
Points:
Points:
Points:
9.9 (11.00%)
7.524 (8.36%)
4.95 (5
Complete details given of other
health problems with full
understanding in relation to
present health problem
explanation and provides detailed
history of previous
hospitalizations and surgeries.
Some details given of other health
problems with partial explanation
in relation to present health
problem with some history
provided for patient’s previous
hospitalization and surgeries.
Vague de
health pro
explanati
health pro
hospitaliz
3 . Family, Culture and E thnic
b ackground
Points:
Points:
Points:
9.9 (11.00%)
7.524 (8.36%)
4.95 (5
Complete information provided
about patient family, provides
cultural point of view in illness and
wellness and connects Ethnicity
to health problems, APA
ref erences
Some inf ormation provided about
patient f amily and cultural point of
view in illness and wellness,
somewhat connects Ethnicity to
health problems, with references.
Vague inf
patient f a
view in illn
vaguely c
health pro
cited
Points:
Points:
Points:
9.9 (11.00%)
7.524 (8.36%)
4.95 (5
Complete information provided
about discharge planning
Some inf ormation provided about
discharge planning.
Vague ab
discharge
Points:
Points:
Points:
9.9 (11.00%)
7.524 (8.36%)
4.95 (5
Complete information provided
with present medical diagnoses
using priority assessment specific
to patient’s status. Example
stroke patient with priority
assessment can identify paralysis
as a complication or inability to
swallow.
Some inf ormation provided with
present medical diagnoses using
priority assessment specific to
patient’s status.
Vague inf
present m
priority as
patient’s
4 . Discharge Planning
5 . Identify complications
o ccurred with present medical
d iagnosis u sing priority
a ssessments specific to
p atient’s status
M eets or Exceeds Expectations
M ostly Meets Expectations
A pproach
6 . Use clinical & psychosocial
a ssessment data to validate
s election o f nursing diagnoses
Points:
Points:
Points:
4.5 (5.00%)
3.42 (3.80%)
2.25 (2
Completely able to provide
rationale f or chosen nursing
diagnosis using clinical and
psychosocial assessment data.
Somewhat able to provide
rationale f or chosen nursing
diagnosis using clinical and
psychosocial assessment data.
Vague in
chosen n
clinical an
assessm
7 . Priority NANDA Nursing
D iagnosis 1 at r isk and 2
a ctual
Points:
Points:
Points:
9 (10.00%)
6.84 (7.60%)
4.5 (5.
TWO (2) actual nursing diagnoses
written correctly per NANDA
f ormat with proper R/T and
Evidence for actual Nursing
diagnosis and R/T f or at risk
Nursing diagnosis.
Written correctly without sufficient
data to support diagnosis.
Written in
data to su
8 . Planning/Goals & Evaluation
Points:
Points:
Points:
9 (10.00%)
6.84 (7.60%)
4.5 (5.
Goal is measurable, realistic,
related to the problem. Data
supports if goal is met, not met
with appropriate revisions.
Goal is not measurable, realistic,
related to the problem. Data
somewhat supports if goal is met,
not met with appropriate
revisions.
Goal is no
realistic,
Data vag
met, not m
revisions
Points:
Points:
Points:
9 (10.00%)
6.84 (7.60%)
4.5 (5.
Lists all MAR medications with
relevant side effects and nursing
considerations specific to patient
and reasons why patient is
receiving drug.
Lists all MAR medications but
does not include relevant side
ef f ects and nursing considerations
specific to patient and why patient
is receiving drug.
Lists mos
medicatio
ef f ects an
specific t
is receivin
Points:
Points:
Points:
9 (10.00%)
6.84 (7.60%)
4.5 (5.
Accurate APA format; Appropriate
citations & ref erences; No spelling
or grammar errors.
1-2 APA f ormat errors; Some
citations, references are
appropriate; Minimal spelling or
grammar errors.
Many AP
Inapprop
ref erence
grammar
9 . Medications
1 0. General Organization
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