Let’s walk through the following forms:
Clinical Assessment Packet
Patient Presentation & Care Plan Concept Map
Last revised: 07/02/2024
Concept Map: The BIG Picture
• A visual tool • A diagram that depicts relationships between concepts • In a concept map, each word or phrase connects to another, and links back to the original idea, word, or phrase.
• Concept maps are a way to developlogicalthinking by
revealing connections and seeing howindividual ideasformalarger whole
Concept Map and Nursing
• Gather data about the patient • Integrate assessment data • Understand the underlying pathologyand laboratory findings • Understand patient history and contributing factors • Prioritize care needs • Develop a plan of nursing care including long and short-term goals
• It is a combination of the tools being used for data collection so that you can assess normal and abnormal findings and thereby create a concept map related to the care your patient needs. • The packet is designed to cover both weeks you are assigned to care for a patient and should be turned in the day that the concept map is due. • The information is to be handwritten because you will obtain most of the information at the clinical site, however some things may need to be looked up outside of the clinical time.
Head to Toe Assessment
• The head-to-toe assessmentform is like the one used in lab. There areacoupleofsmall changesto adapt it to the clinical settings.
• Each packet has 2 copies of this assessment, one for each week youare workingwiththat patient.
OMEGA-7
• OMEGA-7 is at the core of our curriculum. It is an in-depth assessment of each area listed, not a one- or two-word answer • The purpose is to demonstrate an understanding of the pathophysiology of the primary and pertinent secondary diagnoses. The assessment data recorded here will guide you in the creation of your nursing care plan. • There are 2 copies of this tool as well, one for each packet. A secondary purpose is to determine changes in your patient’s condition from week to week. For this reason, the second assessment may simply be “no change in assessment/condition.” • The guidelines for “OMEGA - 7” are on the next few slides.
O
Orientation
• Does the person have a “cognitive” diagnosis? • Is the person oriented to • Person? • Place? • Time? • Situation? •
How does this affect their current health situation and self‐care abilities? • Are there special needs that the person might require? • Include the Patient Cognitive Assessment Scale score
M
Medication
• What medications is the patient taking? • Why? • Does the person know what medications they are taking and why? • Do they require education? •
Are there special instructions or nursing implications that the nurse should note about current medications, monitoring for side effects, needed assessments, allergies/reaction, use of PRN medications?
How does the person take their medications •
•
Whole, Crushed, via Tube, with water, with applesauce/pudding)
• What is the person’s code status? • Are there conditions? • Does the person have other advance directives? • Who is their primary emergency contact? • Would patient have special needs during an emergency?
E
Emergency
G
Gai t
• Does the person have medical diagnoses that are associated with their mobility? • Describe the person have the ability to walk and transfer. • Is their gait steady? • Do they require assistive devices to ambulate or transfer? • Do they require staff assistance? • How many? • For what? • Is the person at risk for falling? • Why? • What is Hendrich Scale score? • What does this indicate? • Are there any mobility issues (balance, gait, ROM, strength, endurance, etc.) that affect ADL self‐care? • What do they prevent the patient from doing? • What assistance do they need with ADLs? • Is the person currently working with PT/OT to improve mobility? • How often?
A
• Does the person have known allergies • Medications • Environmental • Food • Latex • Iodine • Soaps, Lotions • Other •
• How do allergies affect their overall health and lifestyle? • Does the person have current orders for PRN or routine medications for allergies?
Al lergies
What reaction has the patient
had in the past?
• Does the person have respiratory diagnosis or issues? • Is breathing a problem? •
1
Ai r
• Does the person take any medications for respiratory issues? • How often? • Effective? • Any special nursing considerations?
Does the person use oxygen or other assistive devices?
• Are there any potential toxins in the room/outside environments? • What are your significant respiratory assessment findings • O 2 Flow Rate • Mask, • Cannula • Lung sounds • Respiratory Rate & Quality, • Skin color • Cap refill • SpO2
• What is the recommended dietary intake for this person? • Does the person require a special diet related to a medical diagnosis? •
2
Food
• Where does the person eat their meals? • Is this a safe environment? • Do they require assistance with preparation of meal tray or consuming of meals? • Does the person require assistive devices or special set up for meals? • Does the person have orders for dietary supplements? • Why?
ADA, AHA, Edentulous, Aphagia, Renal, etc. • Why?
• Does the person eat well (50%> of meals served)? • Does the person have food preferences? • Any cultural considerations regarding foods or meals?
3
• What is the recommended amount of water intake for this person? • What sources of water has the person had to drink today? • How often did you offer fluids? • How much did they drink (intake)? • Are there any potential toxins or pollutants in the environment that could
Wa t e r
4
Safety
Is the person a safety risk? • Why?
•
• What potential factors might affect the person’s safety? • Does the person demonstrate safety awareness? • Is the person auditory or visually impaired? • How does this affect their safety? • Is the room cluttered or floor wet? • Are there toxic chemicals or other unsafe items in the room/bathroom? • Is the person taking medications that might affect their safety or safety awareness? • What affect might they have? • Are there mobility issues that could affect the person’s safety? • What ADL self‐care is the person able to perform? • What assistance does the person require? • Why? • When was the last linen change? • Last Bath/Shower? • Is the patient continent of bowel/bladder? • Do they use briefs? • Is the person free of odors, clean, and well groomed? • Is there mobility, pain, or other issues that affect the patient’s ability to perform self‐care? • Does the person require education or modifications to improve self‐care?
5
Hyg i ene
6
Is the person in pain? • How does the person describe their pain (location, severity, quality, duration, etc.)? • What has worked in the past to relieve the pain? • Is the pain chronic or acute? • Does the person have prescribed pain medications? • How often are these taken? • Does pain affect the person’s overall health and abilities? • Does the person feel that their pain is adequately controlled? • Does the client require education regarding pain management?
•
Pain
7
• How well is the person sleeping (hours/night)? • What helps the person relax and sleep? • Are there potential factors in the environment that may inhibit sleep (sounds, smells, light)? • Does the person use medication or other alternatives for sleep problems? • How often are these being used? • Are they effective? • Is safety an issue in using them? • Does the person require teaching regarding their use?
Sleep
Lab Results
• At the clinical site, you will need to find your patient’s most recent lab results. • Regardless of whether or not certain labs were drawn, normal values and an interpretation need to be filled out, i.e., why is this lab drawn or what might high, or low results indicate • Abnormal values will need to be addressed on the concept map, so may or may not need to be written down in depth here. For the concept map you will need to know what the normal values are, the patient’s value, and what is going on within the patient’s body related to the primary or pertinent secondary diagnoses that may be causing the abnormal value as well as what it means for the patient, i.e. what s/sx might you see.
Medications
• You will need to look up and know all of the medications thatyourpatientistaking (though the long list of houseprotocolmeds that accompany the new eMAR systems is up to your instructor’s discretion).
• Youneed to know all of your patient’s meds regardlessofwhether or not you canadminister them.
• The medications that are to be listed on the concept mapshouldbe onlythose pertinent to the treatment of the primary and/or pertinentsecondary diagnoses.
Assessment Tools
• These are assessment toolsto help in your assessment. • Morse for the general population • Hendrich for the geriatric population • Theyshouldbe addressed
weekto determine if there is anychange.
Assessment Tools Cont.
• TheBraden and cognitive assessmentshould also be done weekly.
What data are RELEVANT and must be interpreted as clinically significant by the nurse?
Step 1: Recognize Clues
NCSBN Clinical Judgement
Interpreting relevant clinical data, identify the most likely problem(s). Is additional data needed to confirm the significance of clinical cues collected so far?
Step2:Analyze Clues
• Utilize the information from your comprehensive assessment and monitoring of your patient to work through Layer 3 of the NCSBN Clinical Judgement Model. • Layer 3 outlines the cognitive aspects of clinical decision making that are directly measurable.
Rank the most likely problems by urgency.
Step 3: Prioritize hypotheses
Which problem is most likely present? What problem is most concerning? Why?
Step 3: Prioritize hypotheses
Based on the most pressing problem, what are the priority actions?
Step 4: Generate solutions
Step 5: Take action
Evaluate the patient’s response. Recognizing relevant clinical data, has the patient status improved, declined, or remained unchanged?
Step 6: Evaluate outcomes
• Answer the questions in the provided boxes on the table.
If the patient status has not improved, what problem may be present? What additional interventions need to be considered?
Step 6: Evaluate outcomes
SBAR
• The purpose of this form is to be ableto effectively communicate concernsto the physician,charge nurse,casemanager, etc. It is a focused assessmentrelatedto the situation,so every box may not need a response.Whether the inapplicable boxes are left blank or filled inwith “N/A” is up to your instructor’s discretion.
Progress Note
• This is not a journal of what you do all day, but thedocumentation of the care you give to your patient.
• Notetheexpectations forthe number of entries per shift.
• The packet contains 2 pages of SBAR and progress notes at the end sothat they can be pulled off and removed to be turned in at the end of each clinical day.
Grading Rubric
• Both the Concept Map andClinical Assessment Packetsare incorporated into the scoring.
• Meds/labs 5 pts each
Concept Map at Sumner College
Concept Map at Sumner College
The presented information should relate directly to your patient’s primary diagnosis and treatment thereof. This means you should reference only the medications that the patient is on or labs that have been drawn to treat the primary and/or pertinent secondary diagnoses.
The concept map facilitates critical thinking and encourages you to synthesize and extrapolate the information pertinent to understanding your patient’s diagnosis to create an individualized plan of care.
When submitting the concept map, it needs to be exported as a PDF to upload it up to Turnitin. It is possible to save it as a JPEG and inserted it into a Word document, but these are very difficult to read.
There are hundreds of concept mapping sites available for free on-line. A few have been listed to get you started, but feel free to explore and find one that works well for you.
Concept Map: Patient Initials, Primary and Secondary Diagnoses
Diagnoses •
Primary diagnosis is the reason your patient was admitted to the facility.
• Note: In long-term care it is often the reason your patient is still in the facility rather than the reason they were originally admitted
Secondary diagnoses •
•
The patient may have many secondary diagnoses for this map we want • Diagnoses directly related to the primary diagnosis
Diagnoses that may have been a cause of the primary or a result of it
•
Concept Map: Pathophysiology
Describe what is happening in the body as a result of the diagnosis
•
Should be in depth, to the organ, tissue, and cellular level
•
Pathophysiology of secondary diagnoses should describe how they relate to the primary diagnosis
•
Concept Map: Patient Initials, Primary and Secondary Diagnoses
Patient Risk Factors •
What did you assess that puts the patient at risk for the diagnosis?
Common Signs & Symptoms •
What symptoms might anyone with the diagnosis have?
Patient Signs & Symptoms •
What symptoms of the disease does your patient have
If currently asymptomatic, what symptoms did they have on admission or at the time of diagnosis?
•
Concept Map: History of Present Illness
• Summarize what the patient states happened to get them admitted to the facility [or why they are still at the facility] • List manifestations present at onset of the primary diagnosis • From the chart
What treatments did the patient receive? • Meds, labs, surgeries • From the chart
•
How has the disease •
•
effected the patient’s life?
Concept Map: Pertinent Data
Abnormal Lab Results • List the lab •
List normal ranges
List the patient’s results
• •
Relate the pathophysiology of the primary and/or secondary diagnoses as to why the lab may be abnormal Only list the medications that are directly treating the primary or secondary diagnoses
Medications •
List the dose
•
• List the pharmaceutical and therapeutic classification • List why the patient is taking the medication • List nursing considerations related to the medication
Concept Map: References
• Any section that has a * needs to have a reference listed examples can include, but are not limited to: • Nursing textbook • Pathophysiology books • Drug handbooks • Lab result handbooks • Credible websites (no Wikipedia or WebMD!)
Concept Map: Nursing Care Plan
OMEGA-7 Assessment
In assessing the OMEGA-7 elements, issues should arise. These issues should be what drives the creation of a care plan List/describe what you assessed to prove the need for a care plan
•
•
Concept Map: Nursing Care Plan
Give your nursing diagnostic statement
NANDA: directly related to the OMEGA-7 issue described Related to (r/t): needs to be the pathophysiologica l cause, not a medical diagnosis As evidenced by (AEB): your assessment data
•
•
•
Concept Map: Nursing Care Plan
Goals: your instructor will give you specific details
Short-term goal: in general, what you can accomplish within a couple hours or this shift Long-term goal: in general, what can accomplish in a couple of days or weeks
•
S M
Specific
Measurable
A R T
•
Achievable
Realistic
Time referenced
Concept Map: Nursing Care Plan
Interventions: at least 3, all need to have scientific rationale
One that you assess (i.e. vital signs, respiratory patterns) One that you do (i.e. reposition every 2 hours) One that you teach (i.e. new medication teaching
•
•
•
Was your goal met? Yes or no, why or why not.
Concept Map: Discharge
Discharge Summary •
Summarize patient’s stay and the care they received related to the primary diagnosis
Discharge Plan • What is the plan for where the patient will discharge?
• What is needed for the patient to discharge? – Meds, therapies, home health, etc.
Video References
CONCEPT MAPPING: HTTPS://WWW.YOUTUBE.COM/ WATCH?V=VUBLI6IJHHG
HOW TO CREATE CONCEPT MAPS: HTTPS://WWW.YOUTUBE.COM/ WATCH?V=OGAUKEDMZEY
POPLET [FREE SOFTWARE, OPEN SOURCE]: HTTPS://WWW.YOUTUBE.COM/ WATCH?V=THUY_7YBDPO
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32Made with FlippingBook flipbook maker