Case study provided with an example concept map. Must fill in the concept map with all the detailed information based on the case study provided.
6/25/2020
MIA_NURS211L_202006SUI_E-03
Name
NURSING CONCEPT MAP RUBRIC
Description
Rubric Detail
Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
History of
Present
Illness
100.00 %
76.00 %
50.00 %
25.00 %
HPI explained in detail
with accurate and indepth understanding of
chief complaint and
supported by evidence
based citations.
HPI explained in
some detail with
moderate
understanding of
chief complaint or
no support from
evidence based
citations.
HPI explained in limited
detail with marginal
understanding of chief
complaint and no
support from evidence
based citations.
HPI details limited with
poor understanding of
chief complaint and no
evidence based citations
to support.
100.00 %
76.00 %
50.00 %
25.00 %
Identi es
comprehensive
assessments
parameters relevant to
medical diagnoses with
relevant diagnostic
procedures supported
by evidence based
citations.
Identi es most
relevant
assessments
parameters relevant
to medical diagnosis
with relevant
diagnostic
procedures
supported by
evidence based
citations.
Identi es limited
relevant assessments
parameters relevant to
medical diagnosis,
relevant diagnostic
procedures and vaguely
supported by evidence
based citations.
Fails to identify relevant
assessments parameters
relevant to medical
diagnoses, relevant
diagnostic procedures or
not supported by
evidence based citations.
Weight
8.00%
Physical
Assessment, &
Diagnostic tests/
procedures
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Past Medical &
Surgical History,
Pathophysiology
100.00 %
76.00 %
50.00 %
25.00 %
Past medical/surgical
history detailed with full
explanation of
Pathophysiology for
each diagnosis &
accurate details with
speci c detail related to
the client’s history and
symptoms and
supported by evidence
based citations.
Past medical/surgical
history given with
partial explanation
of identi ed
preexisting medical
diagnoses &
explanation accurate
with some detail
related to the client’s
history and
symptoms.
supported by
evidence based
citations.
Past medical/surgical
history given with
minimal explanation of
identi ed preexisting
medical diagnoses & few
details related to the
client’s history and
symptoms or not
supported by evidence
based citations.
No past medical/surgical
history given without
explanation; no preexisting medical diagnosis
identi ed or explanations
inaccurate and not
related to the client’s
history and symptoms
without evidence.
100.00 %
76.00 %
50.00 %
25.00 %
Identi es and de nes
correct stage with
examples of
meeting/not meeting
tasks supported by
evidence based
citations.
Identi es and
de nes correct stage
with examples of
meeting/not meeting
tasks supported by
evidence based
citations.
Identi es correct stage
without adequate
de nition or example of
meeting/not meeting
tasks without evidence
based citations.
Identi es incorrect stage
without de nition or
inappropriate examples
given, not supported by
evidence based citations.
Weight
8.00%
Erikson’s
Developmental
Stages
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Socioeconomic/
Psychosocial
Assessment
100.00 %
76.00 %
50.00 %
25.00 %
Describes
socioeconomic and
cultural background in
complete detail with
references; Identi es 3
psychosocial concerns.
Describes
socioeconomic and
cultural background
in some detail with
references; Identi es
2 psychosocial
concerns.
Describes
socioeconomic and
cultural background in
vague detail without
references; Identi es 1
psychosocial concern.
Describes socioeconomic
and cultural background
with no detail without
references; Identi es no
psychosocial concerns.
100.00 %
76.00 %
50.00 %
25.00 %
Weight
8.00%
Lists 3 or more
appropriate
collaborative
issues/concerns;
Rationale demonstrates
excellent understanding
of consults and
interventions.
Lists 2 appropriate
collaborative
issues/concerns;
Rationale
demonstrates
satisfactory
understanding of
consults and
interventions.
Lists 1 appropriate
collaborative
issue/concern; Rationale
demonstrates vague
understanding of
consults and
interventions.
Lists inappropriate
collaborative
issues/concerns;
Rationale demonstrates
unsatisfactory
understanding of consults
and interventions.
Potential Health
Deviations
100.00 %
76.00 %
50.00 %
25.00 %
Identi es TWO
prioritized risk factors in
proper format; Writes 3
independent nursing
interventions.
Identi es 1
prioritized risk factor
in proper format;
Writes 2
independent nursing
interventions.
Identi es 2 prioritized
risk factors but not in
proper format; Writes 1
independent pertinent
nursing intervention.
Does not identify
prioritized risk factors;
Writes 0-1 independent
nursing intervention not
pertinent to the
diagnosis.
Weight
8.00%
Interprofessional
Consults &
Discharge
Referrals
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Priority
Nursing
Diagnosis
100.00 %
76.00 %
50.00 %
25.00 %
TWO (2) prioritized
diagnoses written
correctly with proper
format with proper
etiology with su cient
data to support the
diagnosis.
One (1) prioritized
diagnoses written
correctly with proper
format with proper
etiology with
su cient data to
support the
diagnosis. Written
correctly without
su cient data to
support diagnosis.
Written incorrectly with
su cient data to
support diagnosis, not a
priority.
Written incorrectly, not in
correct format, or without
su cient data to support
diagnosis.
Weight
8.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Implementation
and
Rationale
100.00 %
76.00 %
50.00 %
25.00 %
Identi es 4
comprehensive nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
appropriate and safe
and demonstrates
clinical reasoning.
Includes nursing and
pharmacological
interventions. Includes
at least 1 health
teaching intervention
that considers health
literacy level and needs
of patient/family.
Includes psychosocial,
spiritual, and cultural
needs. Each is
supported with scienti c
rationale using textbook
or EBP.
Identi es 3 nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
appropriate and safe
and demonstrate
clinical reasoning.
Involved some
independent nursing
and pharmacological
actions. Incomplete
health teaching
activities. Incomplete
psychosocial,
spiritual, and
cultural needs
addressed. Each is
supported with
scienti c rationale
using textbook or
EBP.
Identi es 2 nursing
interventions which
support each SMART
goal and nursing
diagnoses. Nursing
interventions are
inappropriate, but safe
and demonstrates poor
clinical reasoning.
Interventions were
appropriate for the
condition, but did not
take into consideration
the patient’s individual’s
unique needs. Irrelevant
health teaching
activities. Does not
individualize
psychosocial, spiritual,
and cultural needs. Each
is supported with
scienti c rationale using
textbook or EBP.
Identi es 1 independent
intervtion with teaching
Nursing interventions do
not support each SMART
goal and nursing
diagnoses. Does not
demonstrate clinical
reasoning, were
inappropriate or
contraindicated the
nursing diagnosis.
Focused solely on
physician orders and
monitoring and did not
include nursing actions .
Did not mention health
teaching activities. Does
not include psychosocial,
spiritual, and cultural
needs. Are not supported
with scienti c rationale
using textbook or EBP.
Weight
9.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
Planning/Goals &
Evaluation
100.00 %
76.00 %
50.00 %
25.00 %
Goal is measureable,
realistic, related to the
problem; Data supports
if goal is met, not met
with appropriate
revisions.
Goal is not
measureable,
realistic, related to
the problem; Data
somewhat supports
if goal is met, not
met with
appropriate
revisions.
Goal is not measureable,
not realistic, related to
the problem; Data
vaguely supports if goal
is met, not met with
inappropriate revisions.
Goal is not measureable,
not realistic, not related
to the problem; Data
does not support if goal is
met, not met with
inappropriate revisions.
Medications
100.00 %
76.00 %
50.00 %
25.00 %
Weight
9.00%
Lists all MAR
medications with
relevant side e ects and
nursing considerations
speci c to patient and
reasons why patient is
receiving drug. Shows
safe ranges by weight
for infants and children
or gives a rationale if it is
out of range.
Lists all MAR
medications but
does not include
relevant side e ects
and nursing
considerations
speci c to patient
and why patient is
receiving drug.
Shows safe ranges
by weight for infants
and children or gives
a rationale if it is out
of range.
Lists most of the MAR
medications with
relevant side e ects and
nursing considerations
speci c to patient and
why patient is receiving
drug. Shows safe ranges
by weight for infants and
children or gives a
rationale if it is out of
range.
Lists some MAR
medications but does not
include relevant side
e ects and nursing
considerations speci c to
patient. Safe dosages by
weight for infants and
children are missing or
incorrect.
Weight
9.00%
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Levels of Achievement
Criteria
Meets or Exceeds
Mostly Meets
Approaches
Does Not Meet
Expectations
General
Organization
100.00 %
76.00 %
50.00 %
25.00 %
Accurate APA format;
Appropriate citations &
references; No spelling
or grammar errors.
1-2 APA format
errors; Some
citations, references
are appropriate;
Minimal spelling or
grammar errors.
Many APA format errors;
Inappropriate citations
or references; Many
spelling or grammar
errors.
No APA formatting; No
citations or references
included; Many spelling
or grammar errors.
Weight
9.00%
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Concept Map
Student Name:
Instructor:
Erickson’s Developmental Stage Related to pt. & Cite
References (1)
History of Present Illness (HPI), Pathophysiology of Admitting Dx
(Cite References) Medical, Surgical, Social History (1).
Patient Education (In Pt.) & Discharge Planning (home needs)
Medical History
Surgical History
Social History
Cultural considerations, ethnicity, occupation, religion,
family support, insurance. (1) (14)
Chief Complaint
Patient Information
(1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
Diagnostic Test/ Lab Results with dates
and Normal Ranges (3)
Test
Norms
Date
Current
Value
Admitting Diagnosis
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
RT
Freq.
MOA
RN
Considerations
Onset/Peak/
Duration
(Insulin)
Priority nursing diagnosis #1
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Nutrition/Hydration
(8)
GI (9)
GU (10)
Rest/ Exercise (11)
Outcome/Goal #1
Outcome/Goal #2
Integumentary (12)
Endocrine (13)
Psychosocial (14)
Misc. (Ht/Wt)
Interventions # 2
Interventions #1
Assessment/ Evaluation #2
Assessment/ Evaluation #1
PC Outcomes/Goal
Potential Complications/ at
risk for
Priority nursing diagnosis #2
PC Interventions
PC Evaluation Plan
Patient with Stroke
Overview
Stroke occurs when there is ischemia (inadequate blood flow) to a part of the brain or
hemorrhage into the brain that results in death of brain cells. Functions such as movement,
sensation, or emotions that were controlled by the affected area of the brain are lost or impaired.
The severity of the loss of function varies according to the location and extent of the brain
involved. The loss of function may be temporary or permanent. The term brain attack is also
used to describe stroke. This term communicates the urgency of recognizing the clinical
manifestations of a stroke and treating a medical emergency, similar to what would be done with
a heart attack. Following the onset of a stroke, immediate medical attention is crucial to decrease
disability and death. Treatment includes drug and/or surgical therapy, dependent on the type of
stroke, location, timing, and severity of the symptoms. After the patient with a stroke has
stabilized for 12 to 24 hours, collaborative care shifts from preserving life to lessening disability
and attaining optimal function.
Meet your Patient:
T.C. is a 65-year-old African American truck driver who developed weakness of the left side of
his body, loss of vision in one eye, and an inability to speak when getting out of bed this
morning. He sat on the edge of the bed and the symptoms resolved in about 20 minutes. His wife
insisted that she bring him to the emergency department, where he is insisting that he is fine and
doesn’t need to see a doctor and that he has never been sick a day in his life. Over his protests,
you take his vital signs and perform a brief health history and physical assessment. Assessment
findings include the following vital signs: blood pressure 194/108 mm Hg, heart rate 84
beats/minute, respiratory rate 22 breaths/minute, temperature 97.8° F (36.6° C). He moves all of
his extremities well, he has equal grip strength in his hands, and his pupils react equally and
briskly to light. His last visit to a health care provider was 7 years ago when he finally had a
repair of an inguinal hernia that he had had for more than 20 years. He tells you that he doesn’t
smoke or drink alcohol, but he has been a “steak and potato” man all of his life.
Based on the history of T.C.’s symptoms, you suspect that he has experienced a Transient
Ischemic Attack.
With knowledge of cerebrovascular disease, you recognize that T.C.’s symptoms may be caused
by micro emboli breaking off from atherosclerotic plaque located within the carotid artery.
The emergency department health care provider sees T.C. but finds no deficits on neurologic
examination.
A non-contrast head computed tomography (CT) is performed and shows no abnormalities.
The health care provider prescribes aspirin 325 mg PO daily and metoprolol 50 mg PO bid. T.C.
is admitted to the observation unit while awaiting completion of a carotid duplex scan and CT
angiography (CTA).
As you review these orders with T.C., he tells you that his father had a stroke and was
completely helpless for 3 years before he died. He says he would rather just have a big stroke
that would kill him than be disabled.
To encourage T.C. to continue medical care, you advise him that the incidence of stroke can be
reduced by prevention measures can motivate patients at risk to seek close medical supervision
and reduction of risk factors. The TIA is a warning signal that provides for a chance for
prevention of major strokes.
T.C. stayed in the hospital for completion of the carotid scan and CT angiography.
The angiogram revealed a large right internal carotid artery stenosis with a very stagnant flow
and a 50% obstruction of the right middle cerebral artery. The health care provider refers T.C. to
a neurosurgeon who recommends he undergo an endarterectomy of the right internal carotid
artery as soon as possible.
T.C.’s wife is very anxious and asks why he has to have surgery if he hasn’t had a stroke. You
explain that this procedure is performed to remove a plaque in the artery supplying blood to the
brain to prevent a stroke.
A carotid endarterectomy involves the removal of an atherosclerotic plaque and is used to reduce
the frequency of TIAs and the danger of an impending stroke. Because his internal carotid artery
is almost totally occluded, it is important to open the vessel to prevent an impending cerebral
infarction.
T.C. tells you that he wants to wait a few weeks to have the surgery done. He needs to apply for
his retirement pension and Medicare. You tell him you will place a consult with the social
worker to speak with T.C. regarding his financial needs.
Evidence-based practice provides care that is research based but also takes into consideration the
patient’s preferences, values, and needs. Meeting T.C.’s needs so that he can have the surgery
without delay will help prevent a stroke.
Despite consulting with a social worker, T.C. signs himself out of the hospital against medical
advice and schedules the surgery for 3 weeks later.
Unfortunately, before undergoing the scheduled surgery, T.C. awakens one morning with a loss
of motor and sensory function on one side of his body.
His wife calls 911 and he is transported to the nearest emergency department.
An emergency CT scan indicates a moderate-size lesion with a thrombosis of the right middle
cerebral artery.
At this point the treatment options the health care provider might consider are:
✓ Intraarterial or IV tPA = Intraarterial or IV tissue plasminogen activator (tPA) is
administered to reestablish blood flow through a blocked artery to prevent cell death in
patients with the acute onset of ischemic stroke symptoms.
✓ Stroke retriever or Mechanical embolus removal (MERCI) = A stroke retriever or
mechanical embolus removal in cerebral ischemia (MERCI) retriever allows physicians
to go inside the blocked artery of patients who are experiencing ischemic strokes.
Since IV tPA must be administered within 3 to 4.5 hours and intraarterial tPA within 6 hours of
the onset of stroke symptoms, and the onset of T.C.’s symptoms is unknown (occurred while he
was sleeping), the health care provider recommends surgical removal of the embolus as the best
treatment option for T.C.
You explain to T.C. and his wife that this procedure involves insertion of a catheter into the
femoral artery and threading of a corkscrew retriever up to the artery in the brain. The
mechanical embolus removal in cerebral ischemia (MERCI) retriever is a tiny corkscrew device
that uses a microcatheter inserted through a femoral artery balloon catheter. Once the corkscrew
device reaches the clot in the brain, the device penetrates the clot, allowing it to be removed.
After undergoing the MERCI procedure, T.C. is transferred to the neurologic intensive care unit
(ICU).
When assessing T.C.’s status on admission to the ICU, you observe for clinical manifestations
that may be expected in a right-handed person with a stroke with right middle cerebral artery
involvement:
✓
✓
✓
✓
✓
Left-sided weakness
Hemianopsia
Impulsivity
Left-sided paralysis
Greater weakness in upper extremities than lower
A priority nursing intervention at this point would be to keep T.C. NPO until his swallowing
reflex is evaluated. Dysphagia (difficulty swallowing) is a common clinical manifestation of a
stroke, increasing the patient’s risk for aspiration. A speech therapist should be consulted to
evaluate the patient’s swallowing abilities before allowing the patient to eat or drink.
Even though the embolus was removed from T.C.’s middle cerebral artery, he still displays
clinical manifestations related to a stroke.
You note that he has a left hemiparesis that is more pronounced in his upper extremity, drooping
of the left side of his face, drooling, left homonymous hemianopsia, neglect syndrome, and
dysarthria.
Twice he has impulsively tried to get out of bed without calling you for help. He is voiding with
assistance (placement of urinal) and has not had a bowel movement for 2 days.
Based on your assessment data you select the following nursing diagnoses as appropriate for
T.C:
✓ Impaired physical mobility
✓ Impaired verbal communication
✓
✓
✓
✓
✓
Risk of constipation
Risk for aspiration
Risk for injury
Disturbed sensory perception
Unilateral neglect
T.C.’s wife is concerned about his mood and states that he “doesn’t seem like himself.” She tells
you that she thought he would be very angry for not having the carotid endarterectomy when he
initially had his TIA. However, he seems not to care, and often he ignores her when she sits at
his bedside.
Your response to her that his indifference to his situation is a common effect of some strokes,
and he doesn’t see her if she sits on his left side. Indifference to the disability is common with
right brain damage from a stroke, although he may exhibit a quick, impulsive behavioral style.
His left homonymous hemianopsia contributes to his lack of response to his wife if she is on his
left side because he has a cut in his left visual field.
You identify that T.C. has a completed stroke and develop a plan of care for him based on the
identified problems:
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Assess for skin breakdown every shift.
Begin discharge planning.
Coach wife in assisting with patient’s activities of daily living (ADLs).
Gradually move items to affected side as patient demonstrates compensatory ability.
Place chair for transfer from bed on the patient’s unaffected side.
Provide for adequate fluid intake based on T.C.’s individual needs.
Teach patient to consciously attend to left side of body.
Teach patient to exercise left side with right arm and leg.
Transfer to chair for meals.
Turn and reposition q2hr.
The speech therapist is consulted to assess T.C.’s swallowing ability. The speech therapist
assesses that although he does have an intact gag reflex, he coughs when water is provided for
him to drink. To help him swallow, you should flex his head forward and provide small bites of
soft, textured food.
T.C should also remain in a high Fowler’s position, preferably in a chair with the head flexed
forward, for the feeding and for 30 minutes following. Food should be easy to swallow and
provide enough texture, temperature (warm or cold), and flavor to stimulate a swallow reflex.
Pureed foods are not usually the best choice because they are often bland and too smooth. Thin
liquids are often difficult to swallow and may promote coughing.
T.C.’s siblings come to visit and express concerns regarding their risks for having a stroke. You
take advantage of this opportunity to provide teaching regarding risk factors and strokes:
✓ High blood pressure is the leading risk factor for strokes.
✓ Obesity increases the risk for stroke.
✓
✓
✓
✓
A diet high in fat and cholesterol and low in fruits and vegetables will increase your risk.
Smoking increases the risk of having a stroke.
African Americans have a higher risk of strokes than whites.
Increasing exercise is helpful in preventing strokes.
Possible Priority Nursing Diagnoses:
✓ Impaired Cerebral Tissue Perfusion related to intracranial hemorrhage or ischemia
(embolism or thrombosis); as evidenced by …….
✓ Impaired Physical Mobility related to neuromuscular impairment / musculoskeletal
impairment / insufficient muscle strength; as evidenced by …..
✓ Impaired Verbal Communication related to physiological condition / left brain
hemisphere stroke / weakened orofacial musculoskeletal system / insufficient stimuli as
evidenced by.
Please review the information below before starting to work on your Nursing Concept
Map:
The diagnostic statement consists of:
1. Diagnostic label = nursing diagnosis approved by NANDA-I
2. Etiology = the cause or causes of the health problem = “related to”
3. Defining characteristics = “as evidence by” (AEB) = signs and symptoms, subjective and
objective information, and clinical data to support the diagnosis.
Remember that the goals should be timely, realistic, and attainable. Here are two examples:
✓ “Patient will maintain effective cardiac output for tissue needs, within 48 hours, as
evidenced by blood pressure and other vital signs within normal levels.
✓ “Patient will demonstrate use of energy-conservation principles, within one week, as
evidenced by reports of increased energy and ability to perform desired activities”
Remember to include a rational for each nursing intervention, the reason why you are doing that
intervention: Ex. Monitor vital signs to establish a baseline, monitor, and evaluate the patient’s
response to the treatment.
Thank you.