Description
Please don’t expect it if you are not familiar with nursing and health care.Concept Map and Clinical Judgement Map on patient from your clinical unit the same patient for both. I will share the patient you need to fill the rest. See the explanation in the file for the two maps.
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Concept Map/Clinical Judgement Instructions
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U N I V E RS I TY
1847
NURS 420 Adult Health III
Concept Map Instructions and Clinical Judgement Assignment
Dr. Karen Black-Vetter
To obtain credit for any portion, it is imperative that you complete the entire assignment. Complete the patient-related
concept map according to the provided guidelines and complete the clinical judgement section according to the provided
guidelines.
The two sections to complete for this assignment• Part I: The Concept Map based on the Nursing Process
• Part II: Clinical Judgement
Part I: The Concept Map based on the Nursing Process
Patient Information: Pt’s Initials, Age, Gender, Medical Diagnosis, Allergies, and Code Status
Assessment: Subjective and Objective Data (minimum 4 required each- 8 total).
➢
Include relevant Subjective Data relating to Medical Diagnosis- Information provided by the patient,
family, or caregiver. Place in quotations if appropriate.
➢
Include relevant Objective Data related to Medical Diagnosis- Physical Assessment, Diagnostics, Labs,
etc.
Nursing Diagnosis: Actual Problems and Possible Risks reflects the patient’s current condition or main issue. Base the
diagnosis on patient-specific information.
➢
Actual Problem (minimum 3)- Urinary elimination, impairment- indicates disturbance in urinary
elimination.
➢
Possible Risk (maximum 2)- Risk for urinary retention- due to situation, there is a possibility retention of
urine may occur
Plan/Goals/Outcome: Short Term and Long Term (2 required each- 4 total)
➢
Short-Term Goals- focusing on one achievable outcome. Use the SMART pneumonic: Specific,
Measurable, Attainable, Realistic, and Timed. This is important to allow evaluation of patient’s
plan/goal/outcomes by the end of the clinical day.
➢
Long-Term Goals- focusing on a more extended outcome. The full evaluation may not be possible by
the end of the clinical day but by discharge, progress should be assessable. Use the SMART
pneumonic: Specific, Measurable, Attainable, Realistic, and Timed.
Interventions: (Include patient teaching)
➢
Short-term goal (minimum 3)- Ensure these interventions directly correspond to the goal, are patient-specific,
and provide a rationale.
KBV-Spring 2024
Concept Map/Clinical Judgement Instructions
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Long-term goal (minimum 3)- Ensure these interventions directly correspond to the goal, are patient-specific, and
provide a rationale.
Evaluations:
➢
Evaluate each of the short-term and long-term goals.
➢
If the goal was achieved, explain how. If not, analyze whether the patient was progressing toward the goal and in
what manner. Place the goal is “Met”, “Partially Met”, or “Not Met”.
Pathophysiology:
➢
Elaborate on the patient’s pathophysiology in accordance with APA format, incorporating relevant in-text citations
as necessary.
KBV-Spring 2024
Concept Map/Clinical Judgement Instructions
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Part II: Clinical Judgement
Clinical judgment refers to the process by which nurses assess and interpret information, draw conclusions, and make
decisions in the context of patient care. It involves the ability to analyze complex and dynamic situations, integrate
knowledge and experience, and consider various factors to arrive at appropriate and timely decisions for patient
management.
Clinical judgment is essential in healthcare as it guides practitioners in delivering safe, effective, and patient-centered
care. It encompasses critical thinking, problem-solving, and the application of evidence-based practice to ensure that
decisions align with the best available evidence and the unique needs of each patient. Effective clinical judgment
contributes significantly to quality healthcare outcomes and is a fundamental skill for healthcare professionals across
various disciplines.
Breakdown of how to complete Part II of the assignment:
Recognize cues (What Matters Most?)
➢
The filtering of information from different sources (i.e., signs, symptoms, health history, environment).
Analyze cues (What does it Mean?)
➢
The linking of recognized cues to the client’s clinical presentation and establishing probable client needs,
concerns, and problems.
Prioritize hypotheses (Where do I start?)
➢
Establishing priorities of care based on the client’s health problems (i.e., environmental factors, risk assessment,
urgency, signs/symptoms, diagnostic tests, lab values).
Generate solutions (What can I do?)
➢
Identifying expected outcomes and related nursing interventions to ensure a client’s needs are met.
Take actions (What will I do?)
➢
To implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to
promote, maintain, or restore a client’s health.
Evaluate outcomes (Did it help?)
➢
To evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to
which outcomes have been met.
KBV-Spring 2024
Rockford University
NURS 420 Adult Health III Clinical Judgement Map
Recognize Cues-What Matters
Most?
Analyze Cues- What does it
Mean??
Prioritize Hypotheses- Where do I
start?
Pt’s Initial, Age, Gender,
Medical Diagnosis, Allergies,
and Code Status
Evaluate Outcomes- Did it help?
Take Action- What will I do?
MEDICATIONS
Generate Solutions- What can I
do?
Rockford University
NURS 420 Adult Health III Concept Map
Subjective
Subjective Data
Data
Nursing DiagnosisActual and
Objective Data
Risk
Pathophysiology
PlanPlan- Short
Short Term
Term
Plan- Long Term
Pt’s Initial, Age, Gender,
Medical Diagnosis, Allergies,
and Code Status
Evaluation
Interventions- Long Term
MEDICATIONS
Interventions- Short Term
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