ACC The Pathophysiology of Post Partum Hemorrhage Concept Map

Student Name
Clinical Decision Model- Concept Map
West Coast University
Professor Name
Date
Clinical Decision Model-Concept Map
Instructor:
DATE Care Provided and UNIT:
Patient Information
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY
GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC ? WHEN
NEEDED)
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Medical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED MEDICAL PROBLEMS
Code Status:
Living Will/ DPOA:
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
Chief Complaint
Ex: SUBJECTIVE (Abnormal – Bullet Points)
What is the cause of the patients problem
now describing i.e., Pt is having SOB 8/10
with exertion?
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Admitting Diagnosis & Admission
Date
Cultural considerations, ethnicity, occupation, religion, family support, insurance.
(1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health
(SDOH)
?Economic Stability (? MAY DELETE THESE ?TIPS? TO USE SPACE)
? Education
?Social and Community Context
? Health and Health Care
? Neighborhood and Built Environment
Erickson?s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage (based on objective assessment)
Clinical Decision Model-Concept Map
Medical Management and Collaborative Plan
(From MD, PT, OT notes?. etc.) *Consider past 24 ? 48 hours
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(With normal ranges), include dates and rationales supported with Evidence Based Citations
Include 2-3 nursing interventions for abnormal labs and for all diagnostic procedures
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT (? MAY DELETE THESE ?TIPS? TO USE SPACE)
Lab Tests or
Diagnostic Scan
Normal
Ranges
Admission
Lab Values
Current Lab
Values
Explain Abnormal Labs R/T
Your Pt & NI
(USE SEPARATE ATTACHED
WORD DOC ? WHEN
NEEDED)
MEDS
TREATMENT
TIME OUT!!! Student instructions:
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for
hospitalization) Support with Evidence Based Citations
Pathophysiology of Primary Medical Dx (reason for
TIME OUT!!! Student
instructions:
INCLUDE:
Appropriate Diagnostic
Tests/ ProceduresDATEs and RESULTS
(Can add ? See
attached Word Doc)
Ex: The primary pathophysiologic process in COPD is
persistent but variable inflammation of the airways
hospitalization)
Clinical Decision Model-Concept Map
Instructor:
TIME OUT!!! Student instructions:
DATE Care Provided and UNIT:
Medication Name
Dose
Route
Medications & Allergies (2)
Freq.
Indications (PRN
meds must include
MD ordered
Indication)
Mechanism of Action
Side Effects/
Adverse Reactions
Nursing Considerations specific to this
patient with citations
Clinical Decision Model-Concept Map
Instructor:
DATE Care Provided and UNIT:
ASSESSMENT/REVIEW OF SYTEMS
TIME OUT!!! Student instructions:
Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Musculoskeletal (8)
GI/Hydration/Nutrition (9)
GU (10)
Integumentary (12)
Endocrine (13)
Psychosocial (14)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
Respiratory (7)
Ex: Potential Complications. Based on
your research, to what complications
would your patient be prone? List
medical diagnoses- focus on
complications that you can assess for
or prevent. Include potential
collaborative therapy?s (Speech or
Physical Therapy)
psychosocial/discharge planning
complications (Citations required).
What is the cause of the patients
problem describing i.e., Respirations
labored with intercostal retractions?
Lung sounds
Rest/ Exercise (11)
MISC:
Clinical Decision Model-Concept Map
Instructor:
DATE Care Provided and UNIT:
TIME OUT!!! Student instructions:
To be sure your critical thinking statement written below is accurate, you need to review the defining characteristics and related factors associated with and see how your patient data match. Do
you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
Client Needs (SMART GOALS) Ex
Clinical Decision Ex
1.
2.
3.
4.
1.
2.
3.
4.
Impaired gas exchange
Ineffective coping
Ineffective breathing technique
Non-compliant with home medication and 02 use
Assess need for adjustments in O2 flow rate.
Evaluate response to O2 therapy.
Monitor patient for signs of adverse effects of O2 therapy
Teach patient and caregivers about home medication and 02 use
Clinical Thinking + Clinical Reasoning = Clinical Judgement
1.
2.
3.
4.
Pts. w COPD who have exacerbations with poor medication compliance
Pts. w COPD who have exacerbations with anxiety
Pts. w COPD who have exacerbations with PNA
Pts. w COPD who have exacerbations are at risk for acute respiratory failure
Observation
Assessment
Recognize Cues
Obtain information from
different sources (e.g., the
environment, the pt., the family,
another nurse, EHR) in different
formats (e.g., visual observation,
audio perception, lab results, text
description, etc.).
Interpreting
Analysis
Analyze Cues
Interprets cues from their existing
knowledge base and nursing
perspective, evaluate cues in
terms of relevancy, importance,
and interrelationship among other
cues, organize cues in the mental
representation of the scenario
(e.g., organize cues in clusters),
and then develops a group of
probable client needs/concerns
and problems
Responding
Planning
Prioritize Hypotheses
Evaluates the hypotheses
generated previously in various
dimensions (e.g., urgency,
likelihood,
risk/difficulty/time/cost of
providing care to that hypothesis,
etc.), and organize them into an
ordered list where the priority
hypotheses (i.e., client
needs/concerns/problems) are on
the top.
Does the action verb describe the
patient?s behavior to be evaluated?
Can the outcome be used in the
evaluation step of the nursing process
to measure the patient?s response to
the nursing interventions listed
below?
Generate SMART Solutions
Develops a list of actions to address the
priority hypothesis. The candidate then
selects the appropriate action from the
list and carries out the action.
Implement
Take Action
Sorts the hypotheses (probable
client needs, concerns, problems)
in order (based on their
evaluation in various dimensions)
and carries out the action(s) to
address the
hypothesis/hypotheses with
highest priority.
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Reflecting
Evaluate
TIME OUT!! Student instructions:
Do your interventions address further monitoring of the patient?s response to your interventions and to the achievement of the desired outcome? Are qualifiers: when, how, amount, time, and
frequency used? Is the focus of the action?s verb on the nurse. The desired outcome must meet criteria to be accurate. specific, realistic, measurable, and include a time frame for completion.
Evaluation Ex
Compares the outcomes against what was expected (disease progression, unique client response) and decides whether additional clinical decisions are needed for this scenario.
The expected outcomes are that the patient with COPD will: Return 50% to pre-exacerbation baseline respiratory function ? Demonstrate 100% an effective rate, rhythm, and depth of respirations ? Experience decreased
anxiety 100% by effective coping techniques? Maintain clear airway 100% by effectively coughing
Clinical Decision Model-Concept Map
Instructor:
DATE Care Provided and UNIT:
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.

Purchase answer to see full
attachment