Patient RUA

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: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Total points possible: 100 points

Preparing the assignment

Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.

  1. Choose an individual for whom you have cared in the clinical setting.
  2. Create a concept map based on the complete physical assessment you performed while providing care using the provided power point template. 
    1. Components of the concept map
      1. Individual’s information (10 points/10%)
        1. Age
        1. Medical diagnosis
        1. Brief review of underlying pathophysiology

 *List what functional changes are happening

                              *List process that initiated and maintained disorder or disease

  1. Assessment Data (15 points; 15%)
    1. Include all assessment data, not simply information that supports the selected nursing diagnoses

Inspect

Palpation

Percussion

Auscultate

Neurological Exam

  1. Nursing Diagnoses (15 points/ 15%)
    1. Select three nursing diagnoses to addresses
      1. One must be an actual problem
      1. One must address a psychosocial need
      1. The final must be a high priority for the individual
    1. Linkages Within and Between Diagnoses (5 points/5%)
      1. Concept map demonstrates relationship within and between the nursing diagnoses.
    1. Planning (15 points/15%)
      1. Prioritize diagnoses to reflect needs of the individual
      1. Set realistic outcome measurement
      1. At least two (2) scholarly, primary sources from the last 5 years, excluding the textbook, are provided
    1. Implementation (15 points/15%)
      1. Interventions are individualized for patient-provide rationale
      1. Interventions support achievement of selected outcome measurements-provide rationale
  • Evaluation of Outcomes (5 points/15%)
    • Determine if outcomes were met.
    • Provide evidence that supports that determination.
    • Describe what changes, if any, are needed to promote expected outcomes in the future.
    • Safety-Communication-Infection Control 16 points/16%)
      • specific elements of communication used when providing care,
      • safety concerns related to the individual for whom you cared, and
      • infection control practices followed while caring for this patient.
    • APA Citations and Writing (4 points/4%)
      • References are submitted with assignment.
      • Uses appropriate APA format and is free of errors.
      • Grammar is free of errors.
      • Spelling is free of errors.
      • Mechanics of writing are free of errors.

x. Power Point Template (0 points/0%) (deduction if not used)

a. Used provided Power Point Template for assignment completion or an alternate that is approved by faculty.  

For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in your course resources.

Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review module.

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

 

Assignment Section and Required Criteria (Points possible/% of total points available)Highest Level of PerformanceHigh Level of PerformanceSatisfactory Level of PerformanceUnsatisfactory Level of PerformanceSection not present in paper
Introduction of Disease (10 points/10%)10 points9 points8 points4 points0 points
Required criteria AgeMedical diagnosisBrief review of underlying pathophysiology       *List what functional changes are happening        *List process that initiated and maintained disorder or disease  Includes no fewer than 3 requirements for section.Includes no fewer than 2 requirements for section.Includes no less than 1 requirement for section.Present, yet includes no required criteria.No requirements for this section presented.
Assessment Data (15 points/15%)15 points14 points13 points6 points0 points
Required criteria Include all assessment data, not simply information that supports the selected nursing diagnoses Inspect Palpation Percussion Auscultate Neurological ExamIncludes all assessment data.   No requirements for this section presented.
Nursing Diagnosis (15 points/15%)15 points14 points13 points6 points0 points
Required criteria Select three nursing diagnoses to addressesOne must be an actual problemOne must address a psychosocial needOne must be a high priority for the individualThree nursing diagnoses are present and adhere to expectations.   No requirements for this section presented.
Linkages Within and Between Diagnoses (5 points/5%)5 points0 points
Required criteria Concept map demonstrates relationship within and between the nursing diagnoses.Criterion met.  Criterion not met.  
Planning (15 points/15%)15 points13 points6 points0 points
Required criteria Prioritize diagnoses to reflect needs of the individualSet realistic outcome measurementAt least two (2) scholarly, primary sources from the last 5 years, excluding the textbook, are providedIncludes all requirements for section.Includes 2 requirements for section.Includes 1 requirement for section.  No requirements for this section presented.  
Implementation (15 points/15%)15 points13 points0 points
Required criteria Interventions are individualized for patient-provide rationaleInterventions support achievement of selected outcome measurements-provide rationale  Includes all requirements for section.Includes 1 requirement for section.  No requirements for this section presented.  
Evaluation of Outcomes (5 points/5%)5 points4 points2 points0 points
Required criteria Determine if outcomes were met.Provide evidence that supports that determination.Describe what changes, if any, are needed to promote expected outcomes in the future.Includes all requirements for section.Includes 2 requirements for section.  Includes 1 requirement for section.  No requirements for this section presented.
Safety-Communication-Infection Control (16 points/16%)16 points12 points 8 points0 points
Required criteria   1. Describe specific elements of communication used when providing care. 2. Describe safety concerns related to the individual for whom you cared for. 3. Describe infection control practices followed while caring for this patient.Includes all 3 requirements for section.Includes 2 requirements for section.  Includes 1 requirement for section.No requirements for this section presented.
APA Style and Organization (4 points/4%)4 points3.6 points3.4 points1.5 points0 points
Required criteria References are submitted with assignment.Uses appropriate APA format and is free of errors.Grammar is free of errors.Spelling is free of errors.Mechanics of writing are free of errors.Includes no fewer than 5 requirements for section.  Includes no fewer than 4 requirements for section.Includes no fewer than 3 requirements for section.Includes 1-2 requirements for section.No requirements for this section presented.  
Power Point Template (0 points/0%)  0 Points-10 points
1. Power Point template is used to complete concept map (or alternate template approved by faculty.)Includes 1 criteriaDoes not include 1 criteria
Total Points Possible = 100 points
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