Clinical patient clinical judgement

Clinical Patient Clinical Judgement Concept Map

Assignment Instructions

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.

Submission

Word count: 0

4/24/26, 2:45 PM

t BSSR 579/579-A 31 y.o, male DOB: 10/25/1994 CSN: 1070237678 Code Status: FULL Isolation: No active isolations FALL RISK: HIGH FALL RISK: Low Height: 5' 8" (172.7 cm) Weight: 213 1b (96.6 kg) All Diet Orders Placed on Patient (72h ago, onward) None Admit Date: 4/6/2026 Expected Discharge Date: Amina Sadaft MD Active Hospital Problems Diagnosis · Sacral wound, initial encounter · Paraplegia (HCC) · Neurogenic bladder · Normocytic anemia · Hypotension · Infected wound e Pressure injury of skin with infection What Matters to the Patient/Family?: healthy recovery Allergies Allergen · Amoxicillin Apr 24, 2026 Date Noted 04/06/2026 04/06/2026 04/06/2026 04/06/2026 04/06/2026 04/06/2026 04/06/2026 Reactions Hives (Childhood) Past Medical History: Diagnosis •Open wound of lower back and pelvis without penetration into retroperitoneum •Paraplegia (HCC) •Sacral wound, initial encounter Date 02/25 /2026 04/06 /2026 Active LDAs: PICC Line 04/18/26 Wound 04/07/26 Incision 04/06/26 Current Visit Past Procedures Date 04/06/2 026 04/10/2 026 04/13/2 026 04/15/2 026 1330 Single-lumen basilic sacral spine (Active) 1101 sacral spine (Active) (4/6/2026 to Today) SUBCUTANEOUS TISSUE, AND Procedures MUSCLE, TORSO EXCISION, PRESSURE ULCER, SACRAL REGION - N/A EXPLORATION, WOUND, DELAYED PARTIAL CLOSURE AND WOUND VAC PLACEMENT - N/A EXPLORATION, PRESSURE ULCER, SACRAL REGION N/AAPPLICATION OR REPLACEMENT,WOUND VAC N/A vein, right 4 Fr (Active) Providers

Printed by Wesla Taylor, RN [WTAYLOR2] 4/24/2026 2:45 PM 1/2

Wesla list - Last Refreshed: 04/24/26 1445

	Room•		Patient Name/Age/Sex	Code Status		Problem	Pain POSS Due Icon	Diet Orders		Tx Team Sticky Note MEDICAL/SURGICAL	Blank Column
	79		C (31 yo. M)	Full Code		Sacral wound, initial encounter		Diet Regular		/6- ED from Encompass with c/o Sacral wound infection -OR: Debridement of Sacral Wound 4/7- ID cls - IVABX adjusted, wound cx (+)l WORN orders in 4/8- OT reccs ARF; refusing labs 4/9 WBC 11; more necrosis found in sacrum - NPO @ mn, RTOR in am for debridement of sacral wound 4/10 OR excision of sacral wound; advanced to regular diet. Need SW cons for counseling resources? 4/12: pt declined PICC until later date 4/13: RTOR wound vac placement 4/15 Plan for OR, wound vac exchange, refused AM labs 4/16: pt declined PICC d/t risks -Plan for bedside debridement 4/17 -Ethics consulted -Plan for family discussion Monday 4/20 4/18: PICC placed 4/20 Family wound teaching 4/22: d/c home w/mom w/home health, IV abx, wound vac and straight cath. Needs SOC /23: hypotensive 60s/40s MAP 500cc bolus xl -lactate 1.0 Care notes: IVFAbx, Reg, straight cath q6, midodrine TID, Wvac Hx: C7 paraplegic (recent MVA 2/25126 w/ spinal cord injury s/p corpectomy w/ anterior C7, C6-TI anterior cervical discectomy/fusion and C2-T3 posterior cervical dissection(fusion), recently dx UTI 4/4 EDD TBD
	80		Holcomb, R (81 y.o. M)	Full Code		Osteomyelitis of right foot (CMS/HCC) (HCC)		Diet Cardiac/Carb controlled		SURGICAL (PODIATRY) /15 OR: Partial excision of first metatarsal of right foot & wound closure 4/16 PT/OT rec SAR, needs placement 117: AL Cherry Lane - may have bed open tomorrow 4/18: ID consulted - Abx zosyn, path pending - restart coumadin 4/21 : waiting for bed Care notes: NWB Hx: afib, DM EDD: TBD end ath & lacement

Page 1 of 2 Printed by Wesla Taylor on 4/24/26 2:45 PM

Recognize Cues (Assessment) Identify all relevant subjective (0-10 points) and objective assessment information related to the client's condition (0-10 points)

20 possible points (20%)

Analyze Cues (Analysis)- Form hypotheses Based upon assessment information, identify, and prioritize the top 3 client problems. In other words, which 3 assessment findings are of immediate concern? (0-9 points) Below each client problem, determine and enter 2 relevant assessment information that supports the identified client problem. (0-9 points)

18 possible points (18%)

. Prioritize Hypotheses (Analysis) Identify with rationale the assessment findings that the nurse should address first (0-6 points) State priority framework used for the identification (0-3) and rationale for choice (0-3 points)

12 possible points (12%)

Generate Solutions (Planning) What is the desirable client outcome(s)? State 2 outcomes (0-4 points) Identify 3 possible nursing interventions that can be done for the prioritized problem. (0-9 points) State rationale for each intervention (0-3 points) SMART

criteria met for outcomes and interventions (O4 points)

20 possible points (20%)

Take Action (Implementation) Prioritize with rationales the 3 actions the nurse should take to address the priority assessment finding? (0-9 points) What 2 client factors must you consider when making this decision? (0-4 points) How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)? (0-5 points)

18 possible points (18%)

Evaluate Outcomes (Evaluation) - Outcome met with qualifying statement (0-3 points) Outcome partially met with qualifying statement (0-3 points) -Outcome not met with qualifying statement (0-3 points) What additional interventions or assessments should the nurse implement if expected outcome(s) are partially met or not met? (0-3 points)

12 possible points (12%)