26 Apr Clinical Patient Clinical Judgement Concept Map
Choose one patient at clinical to complete a concept map. Paraphrase the patient’s history and physical data ensuring inclusion of the following information to create patient introduction data for the concept map:
History of Present Illness (HPI)
Age: In decades e.g 65 years should be 60s
Gender
Code status
Allergies
Isolation and precaution
VS on admission and date of care. Include POX and pain
Admitting diagnosis
Activity/Functional level
Bowel & Urinary elimination status
Skin integrity
Morse and Braden score
DVT prophylaxis
Labs: Na, K, a, C02, BUN, Creat, glucose, WBC, H/H, Platelet, PT, PTT, and INR
***Provide a minimum of 2 assessment data to support your top 3 prioritized problems
**** Look at the healthcare provider’s assessment and plan under H & P or progress note and patient care orders for assessment and interventions data.
*** If any of the above requested data is not available in your patient’s record, indicate unavailability Note posted concept map care plan guidelines and grading rubric.
