Patient in ICU with a diagnosis of bacterial pneumonia

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 • • Grid View List View Meets or Exceeds Expectations Mostly Meets Expectations Approach 1. Pathopysiology for admitting diagnosis, S/S, Diagnostic test and proposed treatment Points: Points: Points: 9.9 (11.00%) 7.524 (8.36%) 4.95 (5. Patient in ICU with a diagnosis of bacterial pneumonia

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 problems, hospitalizations and surgeries 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 explanatio health pro hospitaliz 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 references Some information provided about patient family and cultural point of view in illness and wellness, somewhat connects Ethnicity to health problems, with references. Vague inf patient fa 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 information 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 information provided with present medical diagnoses using priority assessment specific to patient’s status. Vague inf present m priority as patient’s s 3. Family, Culture and Ethnic background 4. Discharge Planning 5. Identify complications occurred with present medical diagnosis using priority assessments specific to patient’s status Meets or Exceeds Expectations Mostly Meets Expectations Approach 6. Patient in ICU with a diagnosis of bacterial pneumonia

Use clinical & psychosocial assessment data to validate selection of nursing diagnoses Points: Points: Points: 4.5 (5.00%) 3.42 (3.80%) 2.25 (2. Completely able to provide rationale for chosen nursing diagnosis using clinical and psychosocial assessment data. Somewhat able to provide rationale for chosen nursing diagnosis using clinical and psychosocial assessment data. Vague in chosen nu clinical an assessme 7. Priority NANDA Nursing Diagnosis 1 at risk and 2 actual Points: Points: Points: 9 (10.00%) 6.84 (7.60%) 4.5 (5.00 TWO (2) actual nursing diagnoses written correctly per NANDA format with proper R/T and Evidence for actual Nursing diagnosis and R/T for at risk Nursing diagnosis. Written correctly without sufficient data to support diagnosis. Written in data to su Points: Points: Points: 9 (10.00%) 6.84 (7.60%) 4.5 (5.00 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, r Data vagu met, not m revisions. Patient in ICU with a diagnosis of bacterial pneumonia

Points: Points: Points: 9 (10.00%) 6.84 (7.60%) 4.5 (5.00 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 effects and nursing considerations specific to patient and why patient is receiving drug. Lists mos medicatio effects an specific to is receivin Points: Points: Points: 9 (10.00%) 6.84 (7.60%) 4.5 (5.00 Accurate APA format; Appropriate citations & references; No spelling or grammar errors. 1-2 APA format errors; Some citations, references are appropriate; Minimal spelling or grammar errors. Many APA Inappropr reference grammar 8. Planning/Goals & Evaluation 9. Medications 10. General Organization … Patient in ICU with a diagnosis of bacterial pneumonia