CURRENT MEDICAL DIAGNOSIS: Compression Fracture - Fractures

DEFINITION OF CURRENT MEDICAL DIAGNOSIS: Fracture resultin !rom a crus"in !orce on t"e #erte$rae% Fracture is a &isruption in t"e
continuit' o! t"e $one%
SOURCE: (((((((((Me&-Sur Nursin: Critical T"in)in in *atient Care- +
t"
e& ,-.//0(((((((((((((((((((((((((((((((((((((((((((((((((
*AT1O*12SIOLOG2:
A !racture occurs 3"en $one is su$4ecte& to more
!orce t"an it can a$sor$% A compression !racture
results !rom a crus"in !orce t"at "as cause&
&amae to t"e $one% In t"is case5 it is t"e T"oracic
/- #erte$rae% T"e &irection o! a !racture line is
also use& to classi!' !ractures% T"e !racture line
ma' $e o$li6ue5 spiral5 or alon t"e lent"3ise
plane o! t"e $one% As a result o! a T/-
compression !racture5 comes se#ere acute $ac)
pain% Lo3 $ac) pain can rane !rom mil&
&iscom!ort lastin a !e3 "ours to c"ronic
&e$ilitatin pain%
ETIOLOG2:
Ma' $e &ue to osteoart"ritis5 DDD5 &irect7in&irect
#iolence5 or muscular contraction%
Falls5 su&&en t3istin o! t"e spine5
trauma7strainin% Li!tin "ea#' o$4ects an&
puttin e8cess pressure on t"e spinal column%
Li!tin incorrectl'% T"ose patients at ris) !or !alls
,el&erl'7c"il&ren0 ((((((((((((((((((
CLINICAL MANIFESTATIONS
,Sins 9 S'mptoms0:
Loss o! t"e po3er o! mo#ement5 pain 3it" acute
ten&erness o#er t"e site% S3ellin7$ruisin5 &e!ormit'
an& possi$le s"ortenin5 unnatural mo$ilit'5 an&
crepitus% Ma' "a#e so!t tissue in4uries in#ol#in
muscles5 arteries5 #eins5 ner#es in area o! !racture%
Guar&in5 "'po#olemic s"oc)5 muscle spasms5
ecc"'mosis% Decrease in "ei"t5 "ematoma% *ain
3orse 3it" stan&in73al)in% Limite& spinal
mo$ilit'%

LA:7RADIOGRA*1IC FINDING USUALL2
*RESENT:
Dianosis o! a !racture usuall' is con!irme& $'
ra&iorap"ic tests% ;-ra's an& $one scans are use& to
i&enti!' !ractures%
Urine: T"e urine can $e sample& !or mar)ers o!
increase& $one turno#er5 3"ic" occur in persons 3it"
osteoporosis% :loo& tests suc" as a $asic meta$olic
panel5 c"emistr'5 an& C:C ,complete $loo& count0
s"oul& $e o$taine& in an' in&i#i&ual presentin 3it"
an osteoporotic compression !racture% T"'roi&
!unction tests s"oul& also $e o$taine& in patients 3it"
MEDICAL MANAGEMENT
,Inclu&e Treatments 9 Me&ications0
Splintin o! t"e !racture site an& 4oints
a$o#e7$elo3 to limit mo#ement7!urt"er
&isplacement% Col& pac) to site an& ele#ate
a$o#e le#el o! "eart to limit pain an& s3ellin%
Re&uction $' cast until union "as ta)en place%
*"'sical t"erap' a!ter union is complete to
restore site to complete !unction% S)eletal
traction 3it" pins place& in $one an& "el& in
place $' pulle' an& 3ei"t s'stem% :one
stimulation ma' $e necessar' to promote
"ealin% Monitor #ascular an& neuroloical
status o! t"e lim$ &istal to !racture site o!ten%
Analesia to relie#e pain or opioi&s i! multiple
!ractures or !ractures o! lon $ones are a!!ecte&%
Anticoaulants to pre#ent D<T5 stool so!teners
to &ecrease ris) !or constipation secon&ar' to
narcotics an& immo$ilit'% Antiulcer me&s or
antaci&s% ='p"oplast' is common in patients
3it" #erte$ral compression !ractures- t"is is
3"ere a collapse& #erte$ral $o&' is restore& to
its normal si>e an& s"ape 3it" a $alloon5
!ollo3e& $' t"e in4ection o! $one cement to
)no3n or suspecte& t"'roi& &'s!unction%

maintain t"e $one?s s"ape an& strent"%

DISC1ARGE *LANNING
,Client E&ucation0:
Report sins o! impaire& circulation ,col&ness5
num$ness5 tinlin5 &iscoloration5 an& c"anes
in mo$ilit'0 an& teac" "o3 to care !or cast or
splint an& t"e correct use o! assisti#e &e#ices%
Teac" pre#ention o! !alls ,remo#in clutter5
3ell lit rooms5 appropriate s"oes7soc)s5 etc0%
@ell $alance& meals to promote "ealin%
Follo3 MD or&er !or acti#it' an& 3ei"t
$earin% E&ucate patient on appropriate $race
an& "o3 to 3ear it correctl'% A&e6uate calcium
inta)e to pre#ent osteoporosis% Turn usin small
series o! steps%

CLIENT DEVELOPMENTAL STATUS
For each of the following theorists, ientif! the e"elo#$ental stage of the client accoring to age% Then note the
e&#ecte e"elo#$ental tas's for that stage (i%e%, )re#ro*ction an creati"it!+ for Fre*,s Genital, post-puberty
stage-% Ne&t, note how the client is acco$#lishing these e"elo#$ental tas's while in the hos#ital setting% .ow is
this hos#itali/ation affecting their #s!chosocial stat*s at ho$e0 1o* o nee to incl*e Piaget entr! e"en for a*lts,
since cognition can 2e a"ersel! affecte 2! illness, e$entia, $eications, anesthesia, e"elo#$ental eficits, etc%
(The e"elo#$ental tas's nee to 2e incl*e in the conce#t $a#-%
Freud
Genital: Puberty and After- Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment
Encourage separation from parents! achievement of independence! and decision making
"rs " has previously met this stage! and while she is completely alert and oriented! # believe she is having some difficulty successfully meeting this
criteria $he is ready to make her own decisions and be completely independent! but her family is not happy with her decisions $o! they are impairing
her ability to obtain complete independence%decision making because she is conflicted by their feelings of how her health care should progress from
this point $he also has lost a lot of physical independence with her deteriorating health status &hile in the hospital! she is unable to void on her own
and must wear briefs $he has some difficulty feeding herself due to the tremors she has been experiencing $he also is unable to ambulate without
almost total help from the student nurses 'his loss of independence will be a ma(or issue upon returning home to live with her husband! most likely
causing a lot of stress and increased anxiety
Erickson
"aturity: )* years to death- #ntegrity vs +ispair- P,$#'#-E: Acceptance of worth and uni.ueness of one/s own life Acceptance of death 0EGA'#-E:
$ense of loss! contempt for others
"rs " has successfully met this expected stage and is exhibiting the expected behavior while in the hospital $he is well aware of her deteriorating
health status and she knows that this in(ury in con(unction with her long history of pulmonary and cardiac issues may not end well $he is very well
prepared for death and has discussed her wishes with staff $he en(oys telling stories of her past and is content with the life that she has lived $he
had many visitors stop by and she said her goodbyes to all of them $he re.uested to the doctor to be evaluated for 1ospice to visit her in her home
and was discussing the possibility of discontinuing her medications with the doctor 1er family! on the other hand! is not at all ready for her to pass and
cannot accept the possibility of an impending death
Piaget
Formal ,perations Phase: 22 to 2* years- 3ses rational thinking! reasoning is deductive and futuristic
"rs " has met this stage for the most part! but she is having some issues with futuristic thinking $he fre.uently went back and forth on her
willingness to comply with the nursing regimen and her treatment plan ,n day 2! she was discussing placement in a nursing home to provide her
optimal care for her health status 'his day! she got out of bed for almost 4 hours! as opposed to only 45 minutes the day before $he was asking for a
bath! for her hair to be washed and would make comments such as! 6#/ll do whatever # need to do to better my health7 ,n day 4! she was ready to go
to 1ospice! didn/t want a bath at all! refused her meals! and stated that she would be bed bound and never get better # believe she only spoke
futuristically about her own health to make her daughter and husband happy $he did! however! discuss the future of her daughter and husband after
she passes and the help they would need to cope with the loss of "rs "
BRAINSTORMING LISTS
O$4ecti#e Data Su$4ecti#e Data Nursin Dianoses
,All 'ou can t"in) o!0
D'spnea 3it" e8ertion As"a)'B Ris) !or Falls
Nose :lee& A"ot !las"esB Acti#it' Intolerance
Decrease& muscle strent" in !eet Atire&B An8iet'
C"est ;-ra': Car&iomeal' *ain C7/. Ris) !or Unsta$le Glucose Le#el
Lun Scan: CO*D Itc"' Decrease& Car&iac Output
Non-stemi MI D7E @ea) Impaire& Com!ort
:* /D.7FG 1R EC No appetite Ris) !or Constipation
O- G/H RR -. Ris) !or Electrol'te Im$alance
:ilateral &epen&ent e&ema in an)les Ris) !or De!icient Flui& <olume
Sits in c"air 8 -. min Ris) !or Im$alance& Flui& <olume
*ans'stolic murmur Ris) !or D's!unctional Gastrointestinal Motilit'
Tripe $'pass 3it" stent in "eart 9 le Functional Urinar' Incontinence
Dia$etic- T'pe - Ris) !or In!ection
T/- Compression Fracture Ris) !or In4ur'
1'pertension Ris) !or Impaire& Li#er Function
C1F Impaire& p"'sical mo$ilit'
Depression7An8iet' Acute *ain
Aortic Stenosis Ine!!ecti#e *rotection
1'pot"'roi&ism Ris) !or Ine!!ecti#e Renal *er!usion
Anemia Rea&iness !or En"ance& Sel!-Care
MI I7-./- 9 J/. 'rs ao Sel!-Care De!icit: Toiletin
:ruisin on arms an& "an&s Ris) !or Impaire& S)in Interit'
@ea) mo#ements Ine!!ecti#e *erip"eral Tissue *er!usion
Fraile7t"in s)in Impaire& Urinar' Elimination
Troponin T .%./G 1 Impaire& @al)in
Creatinine /%+I 1 Ris) !or Trauma
O- -L NC Impaire& Trans!er A$ilit'
1G: G%G L Deat" An8iet'
1CT C-%+ L E8cess Flui& <olume
Tremors7s"a)in
= C%I ,L0 Cl- G- ,L0
LA3O4ClATO41 DATA
LA3
TESTS
DATES5 )%58 )%9 )%25 )%22 )%24 INTE4P4ET A3NO4MAL 4ESULTS 6 SI7NIFICANCE TO PT
43C8 low 9t frat*re ca*sing 2loo loss%
.g28 Low 9t ane$ia, #ossi2le s9e of Ci#ro%
.CT8 Low 9t s9e of :ana& an Ci#ro
TIME 522* 5:**
25*)
5);5 5*2* 5*44
TEST NAMES NO4MAL
4AN7E
C3C
&<= ;>-225 )2 *9 )5 ----------- >2
Platelets 2*5-:55 459 2>4 45* -----------
?<= :52-:95 ;98 @ ;:8 @ ;85 @ ----------- :45
1gb 24*-2:9 22; @ 99 @ 259 @ ----------- 22: @
1ct ;*8-:>9 ;>5 ;4* @ ;:* @ ----------- ;8*
3MP
0aA 2;:-2:: 2;9 2;8 2;9 2:5 2;8 =l- low d%t diuretic B@asixC causing increased excretion of electrolytes
=reatinine- high d%t history of =1F and cardiomegaly
=,4- elevated d%t cardiac disorders! =,P+! hypothyroidism
Glucose- high d%t stress! type 4 diabetes! medication side effects : =ipro!
@asix! $ynthroid
DA ;*-*4 :4 :2 :5 ;> ;: @
=#- 9>-258 99 255 99 9* @ 94 @
<30 8-4> 4> 48 1 4) 4* 4)
=reatinine 5*>-255 2:5 1 2*: 1 2:* 1 2:5 1 2:4 1
=,4 45-;4 ;4 ;: 1 ;: 1 :5 1 :5 1
Glucose )*-99 22; 1 22; 1 22: 1 25) 1 224 1
Clotting
Factors
(.e$atolo
g!-
P' ----------- ----------- ----------- ---------- -----------
P'' ----------- ----------- ----------- ---------- -----------
#0? ----------- ----------- ----------- ---------- -----------
$ed ?ate ----------- ----------- ----------- ---------- -----------
Misc%
.e$atolog
ies
=PD ----------- ----------- ----------- ---------- ----------- 'roponin '- high d%t impaired cardiac function as a result of "# and
myocardial damage after coronary artery bypass 'roponin EF 5559 552) 1 552; 1 5529 1 -----------
Li"er
F*nction
Tests
(Che$istr!
-
' <ilirubin 55-24 ----------- 54 ---------- ----------- 5: Albumin- low d%t thyroid dysfunction BhypothrydoismC and fluid overload B=1FC
Alk Phos 4*-2)* ----------- >5 ---------- ----------- >4
$G,' 5-:5 ----------- 28 ---------- ----------- 42
Albumin ;*-:> ----------- 48 @ ---------- ----------- ;5 @
Misc%
Che$istrie
s
=aA 8)-254 88 8; @ 92 92 89 =aA- low d%t low albumin levels
"=1=- low d%t iron-deficiency anemia
' Protein- low d%t heart failure G immobiliHation
"gA ----------- ----------- ----------- ---------- -----------
Phosphorus ----------- ----------- ----------- ---------- -----------
"=1= ;2-;> ;5* @ ;5* @ ;2) ----------- 49) @
'otal Protein )5-8* ----------- ** @ ---------- ----------- )*
A37
p1 ----------- ----------- ----------- --------- -----------
P=,4 ----------- ----------- ----------- ---------- -----------
1=,; ----------- ----------- ----------- ---------- -----------
P,4 ----------- ----------- ----------- ---------- -----------
Other;
(List Na$e
an
Nor$al
4ange-
<ld =ulture ----------- ----------- ----------- ---------- ----------- =loudy Appearance: possible 3'#
Protein- possible 3'#
3 <ili- =1F
<lood- possible 3'# or from trauma of fall
3 &<=- Acute 3'#
3rine=ulture ----------- ----------- ----------- ---------- -----------
3rinalysis: ----------- ----------- ----------- ---------- -----------
Appearance =lear ----------- =loudy ---------- -----------
Protein 0eg ----------- IF ;55 ---------- -----------
3 <#@# 0eg ----------- $mall ---------- -----------
<lood 0eg ----------- $mall ---------- -----------
3 &<= 5 ----------- *-25 ---------- -----------
<acteria 5 ----------- ; A ---------- ----------- <acteria- Possible 3'#
A%G ?atio 5>-45 ----------- ----------- 25 ----------- 59 @ A%G ?atio- Possible 3'#
A@'%$GP' 5-:5 ----------- 9 ---------- ----------- 8
?+&-$+ ;82-:92 *>: 1 *>) 1 **) 1 **: 1 ?+&- high d%t iron-deficiency anemia
?+&-=- 228-2:9 2)8 1 2)9 1 2)8 1 2)* 1 ?+&- high d%t iron deficiency anemia
"P- 89-224 249 1 22: 1 245 1 22) 1 "P-- high d%t +" and anemia
P"0J *5->5 >8) 1 85; 1 8;; 1 8:> 1 P"0- 1igh d%t recent "# on )%9%2:
@K" J 4*-:5 242 @ 99 @ 9* @ >> @ @K"- low d%t anemia! renal cysts
E,$ J 2-) 28 5* @ 5; @ 58 @ E,$- low d%t stress and possible s%e of lasix
A<$ @K"P1 2-:* 5> @ 5) @ 5) @ 5) @ A<$ @ymph- low d%t anemia and risk for infection
DIA7NOSTIC TESTS
=hest L-?ay B+ates G ?esultsC
)%>%2: 44:;4
=ardiomegaly $mall bilateral layering pleural effusions
)%22%2: 2:;*
"ild cardiomegaly unchanged =lear lungs 0o interval change
EDG B+ates G ?esultsC
,ther ?adiographic $tudies B+ates G ?esultsC
=' w%o contrast cervical )%>%2: 44:28
0o acute fracture or dislocation "ild degenerative changes @ow density pleural effusions
noted at lung aspices
=' lumbar )%>%2: 44:28
Acute mild compression fracture of superior endplate of '24 -ertebral body producing
approximately 4*J loss of vertebral body height centrally
=' pelvis )%>%2: 44:;4
0o acute fracture or dislocation $een mild degenerative changes at both hip (oints $acroiliac
(oints and pubic symphysis
"?# lumbar w%o contrast )%8%2: 24:;4
2 Acute compression fractures superior endplate '24 with loss of vertebral height centrally of
approximately 4*J 'here is minimal retropulsion of the superior endplate into the central
canal with no significant central spinal canal stenosis
4 $ignal abnormality noted with the $4 and $; vertebral bodies incompletely evaluated most
likely the result of acute in(ury in this patient with acute '24 fracture
; "ild multilevel degenerative changes
: Probable bilateral subcentimeter renal cysts
* @eft adrenal nodule measuring 48cm which has remained stable when compared to ='
scan on $eptember 8!455:
,ther +iagnostic 'ests- B+ates G ?esultsC
)%22%2: 2:;; @ung $can
"atched defects consistent with =,P+
CU44ENT MEDICATIONS <O4=S.EET
T4ADE97ENE4IC
NAMES
DOSE
O4DE4ED
AND
4OUTE
TIME
7IVEN
CLASSIFICATION
AND ACTION
DOSA7E
4AN7E
4ATIONALE FO4
ADMINIST4ATION
SIDE
EFFECTS
NU4SIN7
IMPLICATIONS
AlpraHolam
Lanax
54* mg
P,
5955
4255
Antianxiety!
<enHodiaHepine
Acts on =0$ to
produce anxiolytic
effect =0$
depression
54* M 5*
mg! 4-
;x%day
0o more
than :
mg%day
Patient has history
of anxiety $he
takes this to
decrease anxiety
+iHHy!
drowsy!
lethargy!
confusion
0%-%+!
constipation
Assess level of anxiety!
drowsiness! risk for falls
"onitor for dependence!
=<=! liver! renal function
tests @owers 1ct and
0eutropenia FlumaHenil for
,+
=alcitonin $almon
"iacalcin 0asal
$pray
2 spray!
nasally
5955 1ypocalcemic!
1ormones
#nhibits osteoclastic
bone resorption and
promotes renal
excretion of =a
2 spray
B455
unitsC%day
'o decrease rate
of bone turnover
and lower serum
calcium
Anaphyla
xis! 1%A!
?hinitis!
arthralgia!
facial
flushing
,bserve for
hypersensitivity Assess
nasal mucosa! septum
"onitor =a! alk phos
=iprofloxacin
=ipro
4*5 mg P, 5955
4255
Anti-#nfective!
Fluoro.uinolone
#nhibits bacterial
+0A synthesis!
bacteriocidal
4*5->*5
mg N241
'o treat bacterial
infection
##=P!
hepatotoxici
ty!
pseudome
mbranous
colitis!
anaphylaxis
Assess for infection!
anaphylaxis "onitor bowel
function OA$'%A@'! @+1!
bilirubin! alk phos =an
increase or decrease
glucose
Ferrous $ulfate
#ron
;4* mg P, 2455 Antianemic! #ron
$upplement
Enters
bloodstream
where it becomes
part of iron stores
4-; mg%kg
per day in
4-:
doses
'o prevent iron
deficiency anemia
=onstipati
on!
epigastric
pain! G#
bleeding!
diHHiness
Assess nutrition status!
bowel function for
constipation or diarrhea
"onitor 1G1
+eferoxamine is
anecdote for toxicity
Furosemide
@asix
45 mg P, 5955 @oop +iuretic
#nhibits
reabsorption of 0a
and =l from loop
of 1enle and distal
tubules O
excretion of 14,!
0a! =l! "g! D! =a
45-85
mg%day!
up to 4*
g%day
'o treat 1'0 by
lowering <P
Erythema
multiform!
stevens-
(ohnson
syndrome!
toxic
epidermal
necrosis!
aplastic
anemia!
agranulocyt
osis
Assess FGE status! monitor
weight! #G,! edema! lung
sounds "onitor <P G 1?
before%during admin Assess
for tinnitus G hearing loss!
rash "onitor glucose! uric
acid "ay O <30! glucose!
creatinine! uric acid
@evothyroxine $od
$ynthroid
>* mcg P, 5955 1ormone%'hyroid
Preparations
?eplacement of
thyroid hormones!
increases
metabolic rate of
body tissue
2*
mcg%kg%d
ay
'o treat
hypothyroidism by
restoring normal
hormonal balance
#nsomnia!
#rritable!
O1?!
arrhythmi
as 1eat
intoleranc
e
Assess apical pulse and
<P before%during
admin Assess for
tachyarrhythmias and
=P "ay increase
glucose "onitor thyroid
function
CU44ENT MEDICATIONS <O4=S.EET
T4ADE97ENE4IC
NAMES
DOSE
O4DE4ED
AND
4OUTE
TIME
7IVEN
CLASSIFICATION
AND ACTION
DOSA7E
4AN7E
4ATIONALE FO4
ADMINIST4ATION
SIDE
EFFECTS
NU4SIN7
IMPLICATIONS
"etoprolol 'artate
@opressor
*5 mg P, 5955 Antihypertensive!
<eta <locker
<locks stimulation
of beta 2
adrenergic
receptors
4* mg M
255 mg%day
usually 3p
to :*5
mg%day #?
or :55
mg%day E?
'o treat
hypertension and
lower <P
@ow 1?!
1F! Pulm
edema
Fatigue!
weakness
"onitor <P and 1? fre. #f
1? E:5! admin atropine
54*-5* mg #- "onitor #G,
and daily weights Assess for
$%$ of 1F Bdyspnea!
crackles! Oweight! (ugular
distentionC O <30! D! uric
acid O glucose! alk phos!
@+1! A$'%A@'
$odium =hloride PF
-ial
0a=l 59J
25 m@ #- 5955
4255
"ineral%Electrolyte
?eplacement
"aintains water
distribution
2*5 me.
0a%@
?ate%amoun
t
determined
by condition
'o reconstitute vial
for admin or to
flush #- line
1F!
Pulmonar
y edema!
irritation
at site
Assess FGE balance!
#G,! weight! edema!
lung sounds Assess for
hypo%hypernatremia
"onitor 0a! D! bicarb!
and =l-
=lonidine 1cl
=atapres
52 mg P, N)1
P?0
Antihypertensive!
Adrenergic
$timulates alpha-
adrenergic receptors
in =0$! decreasing
sympathetic outflow!
decreasing <P
Prevents pain signal
transmission to =0$
by stimulating alpha-
adrenergic receptors
in spinal cord
3sual
dose 54-
5)
mg%day!
up to 4:
mg%day
'o lower <P +rowsy!
dry
mouth!
withdrawa
l
"onitor #G,! daily
weight! edema "onitor
<P G 1? before%during
tx O Glucose
4O<AN8CA3A44US COMMUNIT1 COLLE7E
NU4SIN7 P4O74AMS
NU4 >>?9?>>A3 Criteria for E"al*ation of Conce#t Ma##ing an Scoring 4*2ric
4e"ise @?9>A9>B
Criteria E&e$#lar! Satisfactor! Nees I$#ro"e$ent Unsatisfactor! Score
'he following criteria will be used to evaluate
student performance of competencies related to
concept mapping
C POINTS
>% E&cees
e&#ectations as
o*tline in the
learning acti"it!
criteria%
?% Consistentl! oes
all or al$ost all of
the following;
D POINTS
>% Meets
e&#ectations 2! f*ll!
aressing the
learning acti"it!
criteria%
?% Does $ost or
$an! of the
following;
> POINT
>% Does not f*ll!
$eet e&#ectations
2! inco$#letion or
fail*re to f*ll!
aress the learning
acti"it! criteria%
?% Does $ost or
$an! of the
following;
@ POINTS
>% Does not $eet
e&#ectations 2ase
on the learning
acti"it! criteria%
?% The assign$ent is
not s*2$itte%
D% Consistentl! oes
all or al$ost all of
the following;
I% Clinical Pre#9Pre8Clinical Manager Data;
U#ate Sections as A##lica2le on Da! ?
2 $im=hart Pre-=linical "anager includes
diagnosis section
4 $im=hart ,rder EntryPgeneral orders
include activity and mobility! alerts! code
statusQ nutrition orders Bdiet and fluidsC
; $im=hart Admission 1istory completed in
Patient =harting section Ball areasC
: Pathophysiology sheet is complete
according to assigned text sources G
relevant to client admission
* +evelopmental status notes Erikson!
Freud! Piaget stages! expected tasks! G
how client meets in hospital
D% @ab and diagnostic test sheets completed
with interpretation of results for individual
client
a% All areas are
co$#letel! an
acc*ratel! recore
with *#ates note
2% Ientifies all la2
an9or iagnostic
res*lts for s#ecific
client
a% So$e areas are
not aresse, no
*#ates are note
2% Ientifies all
a2nor$al la2 an9or
iagnostic res*lts
for s#ecific client
a% Inacc*ratel!
recors an9or
$isinter#rets ata
2% Inacc*ratel!
recors an9or
$isinter#rets la2
an iagnostic
res*lts for s#ecific
client
a% Fails to re#ort #re8
clinical ata
2% Fails to ientif!
la2 an9or
iagnostic res*lts
for s#ecific client
II% Plan of Care Ma#9N*rsing Process For$at
an Content;
2 6<rainstorming7 section complete with list of
ob(ective and sub(ective clinical
manifestations and complete list of
potential nursing diagnoses individualiHed
for assigned client
4 "ap is created on clean! unruled BblankC
white paper
; Assessment data is complete and
integrated into the plan of care map
: 'eaching Plan is outlined in detail on back
of plan of care map
* All concepts are enclosed inside a symbol
or shape
) 0ursing diagnoses are numbered
according to priority
> <oth sub(ective and ob(ective data are
provided
8 Each nursing diagnosis includes an
etiology Br%t! brief explanation of pathophysC
and clinical manifestations BA"<! signs!
symptomsC
9 'he meaning of relationships within
concepts is indicated by connecting lines
with linking words or abbreviations Br%t!
amb! patient will! nurse will! etcC
25 Goals and outcomes are measurable
22 $tated nursing care is appropriate for
specific client
24 +ata from the initial assessment is listed in
black
2; ,ngoing assessment as collected is listed
in red
2: $hapes or symbols are outlined using the
=oncept "ap =olor Dey
2* 'he plan of care is legible
2) Assessment data is integrated into the
concept care map
2> =ross-links between concepts illustrate
valid relationships uni.ue to the client using
red lines with linking words
a% All n*rsing
iagnoses are
correctl! n*$2ere
2ase on #riorit!
2% #entifies fi"e (C-
or $ore
relationshi#s
2etween conce#ts
c% 4e"ises the
conce#t $a# 2ase
on e"al*ation of the
o*tco$es
% ientifies $ore
than C
a##ro#riate9#riorit!
n*rsing iagnosis
a% Correctl!
#rioriti/es highest
#riorit! iagnosis
2*t incorrectl!
n*$2ers others
2% #entifies three (D-
or $ore
relationshi#s
2etween conce#ts
c% So$e re"isions
are $ae
% ientifies C
a##ro#riate9
#riorit! n*rsing
iagnosis
a% Incorrectl!
#rioriti/es all
n*rsing iagnosis
2% Ientifies less
than three (D-
relationshi#s
2etween conce#ts
c% Few re"isions are
$ae
% ientifies few than
C a##ro#riate9
#riorit! n*rsing
iagnosis
a% Does not #rioriti/e
an! n*rsing
iagnosis
2% Fails to ientif!
or incorrectl!
ientifies
relationshi#s
2etween conce#ts
c% No re"isions are
$ae
% Fails to ientif!
a##ro#riate9#riorit!
n*rsing iagnosis
EEEEEE
III% Doc*$entation; (Incl*es Si$Chart an9or
.os#ital Co$#*ter Charting-;
2 $ystems Assessment data are complete
and accurate for each day of care <raden
scale and "orse Fall $cale completed
4 -ital $igns are accurately recorded daily
; &ounds! drains% tubes! ostomies recorded
daily as applicable
: #ntravenous fluids and related data are
recorded daily B#G, sectionC
* #- and #n(ection sites are recorded daily
) 'reatment information is listed daily
> +iet%fluids and appetite data and
elimination data are recorded daily BJ
eaten and #G,! <"s recordedC
8 Psychosocial%cultural data is complete
9 <asic 0ursing =are is complete and
accurate BdailyC
25 Applicable nursing interventions for each
listed body system are accurately recorded
BdailyC
22 Patient 'eaching is recorded daily
24 +ischarge Planning section completed
2; 0arrative physical assessment notes are
clear! concise! factual! accurate! complete!
current! and organiHed
2: =orrect grammar! punctuation! spelling!
and approved agency abbreviations used
a% Thoro*ghl! an
co$#letel!
oc*$ents Da! >
assess$ents an
client care
inter"entions in
Si$Chart% Narrati"e
co$$ents are well8
written, an client
s#ecific, acc*ratel!
reflecting client
stat*s%
b On Da! ?,
oc*$ents well8
written, client
s#ecific narrati"e
#h!sical assess$ent
note that
e$onstrates
e&ce#tional ecision
$a'ing an
acc*ratel! reflects
client stat*s%
a% Doc*$ents Da! >
assess$ents an
client care
inter"entions in
Si$Chart% As
narrati"e co$$ents
reflecting client
stat*s%
%
2% On Da! ?,
oc*$ents narrati"e
#h!sical assess$ent
note that
e$onstrates
#ro2le$ sol"ing
s'ills an acc*ratel!
reflects client stat*s%
a% Da! > Si$Chart
oc*$entation has
so$e co$#onents
that fail to acc*ratel!
reflect client stat*s%
2% Fails to acc*ratel!
oc*$ent Da! ?
narrati"e #h!sical
assess$ent note to
reflect client stat*s,
e$onstrating #oor
ecision $a'ing an
#ro2le$ sol"ing
s'ills%
a% Da! > Si$Chart
oc*$entation
contains erroneo*s,
irrele"ant ata that
o not reflect client
stat*s%
2% Da! ? narrati"e
assess$ent note
contain erroneo*s,
irrele"ant ata with
no #ro2le$ sol"ing
s'ills e$onstrate%
EEEEE
IV% Self8E"al*ation
2 $tudent completed self-evaluation using 6'he
=offeehouse7 on <lack<oard
4 $tudent followed directives given for +iscussion
<oard for current clinical week
; $tudent responded to at least 4 peers each
week with a constructive and supportive
comment
a% Thoro*gh an
insightf*l
co$#letion of all
reF*ire$ents of the
self8e"al*ation #iece
of the r*2ric
2% St*ent
res#one to $ore
than ? st*ents with
constr*cti"e an
s*##orti"e
co$$ents
a% St*ent
co$#lete all
reF*ire$ents of the
self8e"al*ation #iece
of the r*2ric
2% St*ent
res#one to ?
st*ents with
constr*cti"e an
s*##orti"e
co$$ents
a% St*ent i not
co$#lete all
reF*ire$ents of the
self8e"al*ation #iece
of the r*2ric
2% St*ent
res#one to >
st*ent with
constr*cti"e an
s*##orti"e
co$$ents
a% St*ent i not
co$#lete the self8
e"al*ation
2% St*ent i not
res#on to an!
st*ents
EEEEEE
EEEEE
TOTAL SCO4E
CONCEPT MAP =E1;

Nursing
Diagnosis

Green


Assessmen
t
Purple
Pathophysiolo
gy
Blue
Interventio
ns
Yellow
Planning
Goals,
Outcomes
Orange
Evaluati
on
Re

Lin'ing Line Arrow Cross8Lin' Line Arrow Lin'ing <ors
(3lac'- (4e- (Pencil-
Instr*ctor Co$$ents;
'he $tudent must score a minimum of 6;7 to achieve competency for the assignment
'otal $core RRRRRRRRRRRRRR divided by 625 7 to get the Assign$ent Score G EEEEEEEEEEEEEEEEEE
Unsatisfactor! E"al*ation 4e#orte to the Clinical Co8coorinator on EEEEEEEEEEEEE%
S#ecif! 4e$eiation for Score Less Than D an D*e Date ($*st 2e #rior to ne&t clinical assign$ent-EEEEEEEEEEEEEEE%
RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR
#nstructor/ $ignature +ate $tudent/s $ignature +ate