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Student Name: Date: Complete the following: Nursing Assessment and clinical map.
2.As the day progresses, update assessment, diagnoses, interventions and outcomes.
3.Place an asterisk (*) by the priority nursing diagnosis and draw arrows to reflect
4.Complete patient evaluations at the appropriate time.
5.Clinical Maps must reflect the care actually provided.
6.Use a highlighter to indicate additional interventions for your client.
7.Clinical Maps must be turned in one week after the clinical day.

Grading Criteria for Clinical Map Points

1. Assessment
-Initial Data Collection (medical dx, priority assessment data needed) 4
-Assessment Data (update throughout the clinical day) 6
2. Diagnosis
-Cluster Supporting Data 6
-Formulate 2 (two)Nursing Diagnoses 4
3. Planning
-Prioritize Nursing Diagnoses 10
-Develop (at least 3) Expected Patient Outcomes 20
-Develop Appropriate Nursing Interventions (update throughout the day) 5
4. Implementation
-Implement Planned Interventions 15
-Continuous Reassessment 10
5. Evaluation
-Evaluate Patient’s Response to Nursing Care (Outcomes M, NM, PM) 10
-Revision of Plan of Care 10


Nursing Diagnosis

Acute pain related to surgical incision

Assessment: Outcomes:
Objective: 1.) The patient will demonstrate understanding of
1. )B/P 98/60 controlling her pain by pressing the button on her
2.) P 97 PCA pump every 10 minutes.
3.) R 18 2.) The patient will be satisfied with pain relief in
4.) T 97 10-30 minutes.
5.)SaO2 98% RA 2.) The patient pain will be controlled to prevent
Subjective: interference with postoperative recovery by PCA
Age: 36 pump on 4/6/2011.
Gravida: 5
Para: 1
Patient states that she feels some pain at her
incision sight.

Interventions: Evaluation:
1.) Teach and assess patient’s correct use of 1.) The patient verbalized understanding about
patient-controlled analgesia to ensure the use of the PCA pump.(M)
effectiveness in PACU and upon returning to 2.) The patient is satisfied with the relief of pain
the floor. controlled by the use of the PCA pump.(M)
2.) The nurse should use pain control
measures before pain becomes severe by
making sure patient is getting a high enough
dosage through the PCA pump.
3.) The nurse should assess pain for character,
location, and effectiveness of relief measures
every 4 hours.
Modifications in Plan of Care

The nurse will continue to monitor the patient for any changes and notify the physician if needed.

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