Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 1

South University Virginia Beach

Clinical Concept Map/Care Plan

Purpose:

The clinical concept map/care plan interrelates core concepts and facilitates the student to prioritize the diagnosis of patient care.

Background:

Students are to complete the clinical concept map/care plan in the following courses, with requirements as listed in table below:

Clinical Practice Course Number of Nursing Number of Care Plans Per Term
Diagnosis Interventions
NSG3024 2 5 2
Fundamentals
NSG3038 4 5 4
Caring for Adults I
NSG3045 4 5 4
Caring for Adults II
NSG4053 5 5 4
Caring for Adults III
NSG4061 5 5 1-ICU/ED
Caring for Adults IV 2- MS/Stepdown
NSG3048 4 5 4
Nursing Care or Women and Neonates
NSG4057 4 5 4
Nursing care of Children

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Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 2

Directions:

 Utilize the template provided below to complete the Clinical Concept Map/Care Plan

 Provide basic information about the patient, including the medical diagnosis in the middle box

 Utilize the surrounding boxes to develop a plan of care for the patient.

 Remove boxes as necessary depending on what is applicable for the course

 Once the information is completed in the map, draw or place lines between the diagnoses to relate the concepts

 Also please color-code the concept map for better understanding for the reader

 The rubric for the concept map/care plan grades the concept map and care plan, as one grade.

 Nursing diagnosis:

o When choosing a nursing diagnosis, do no repeat the use of any nursing diagnosis more than two times, per term

o Utilize a nursing diagnosis that covers client need category as found from the NCLEX test plan blueprint (below).

NCLEX Test Plan Client Need Categories

Safe and Effective Care Environment
 Management of Care
 Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
 Basic Care and Comfort
 Pharmacological and Parenteral Therapies
 Reduction of Risk Potential
 Physiological Adaptation

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Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 3

Clinical Concept Map/Care Plan

Demographics: Information concerning the patient (such as age, marital status, allergies, medical and surgical history, code status, and any
testing that may have been done during the present admission.)

SBAR

Situation Pt is a 61y.o male admitted for an acute CVA with right sided weakness.

Background Pt has a history of LMCA was dischargedfrom NGH had another stroke on 7/19 with right sided weakness. Pt also has a
history of hypertension and cocaine abuse.

Assessment Pt is aphasic and has a persistant right sided weakness. Ct of the head shows elvoving stroke with signs of tissue necrosis
with no hemmorage

Recommendations Pt is scheduled for a TEE and is being monitored for changes in LOC.

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Pathophysiology: A middle cerebral artery (MCA) stroke is one of the most widely recognized large vessel strokes. A stroke is
usually named by the injured part of the brain or by the blocked blood vessel, and an MCA stroke is an interruption of blood flow to
the areas of the brain that receive blood through the middle cerebral artery. These regions include the frontal, parietal, and temporal
lobes as well as the internal capsule.

Priorit Nanda Rationale for Prioritization

y

1 Ineffective cerebral tissue perfusionr/t left acute

infarcation AEB worsening right sided weakness.

2 Impaired mobility r/t LMCA CVA as evidence by

asphasia

3 Activity intorlerance related to immobility as evidence by

total right side weakness

4 Hopelessness r/t deteriotating physicological condition

AEb ongoing stroke causing necrosis of the brain tissue

Insert Medication list here:

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Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 5

Nursing diagnosis #1: Ineffective cerebral tissue perfusionr/t left acute infarcation AEB worsening right sided
weakness.

Outcome(s): Demonstrate behaviors and lifestyle changes to promote healing and prevent complications or
recurrence.

Nursing interventions Scientific Rationales (citation) Evaluation

1. Identify underlying conditions or 1. Assess for individual factors that can result in
pathology. tissue damage or can impede healing.

2. Determine psychological effects of 2. Can be devastating for client's body or self-image

condition on client/significant other.
3. Descriptive text is not available for this
imageProvide or encourage optimum
nutrition including adequate protein,
lipids, calories, trace minerals, and
multivitamins.
and esteem, especially if condition is severe,
disfiguring, or chronic, as well as costly and
burdensome for SO(s)/caregiver.
3. to promote tissue health/healing and adequate
hydration to reduce and replenish cellular water loss
and enhance circulation.

4. Help client and family identify effective 4. to reduce pain or discomfort and to improve
successful coping mechanisms and quality of life.
implement them to reduce pain or
discomfort and to improve quality of life. 5. to facilitate tissue healing and prevent
complications associated with lack of knowledge
5. Review medical regimen with patient about maintaining tissue integrity.

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Nursing diagnosis #2: Impaired mobility r/t LMCA CVA as evidence by asphasia

Outcome(s): Participate in activities of daily living (ADLs) and desired activities. Demonstrate techniques or
behaviors that enable resumption of activities.

Nursing interventions Scientific Rationales (Citation) Evaluation

1. Note factors affecting current situation
and potential time
2. Assess client's developmental level,
motor skills, ease and capability of
movement, posture, and gait.
3. Determine degree of immobility in
relation to 0 to 4 scale, noting muscle
strength and tone, joint mobility,
cardiovascular status, balance, and
endurance.
4. Note emotional/behavioral responses to
problems of immobility.
5. Perform and encourage regular skin
examination and care.
1. Identifies potential impairments and determines
types of interventions needed to provide for client's
safety.
2. to determine presence of characteristics of
client's unique impairment and to guide choice of
interventions.
3.. Identifies strengths and deficits and may provide
information regarding potential for recovery.
4. Feelings of frustration or powerlessness may
impede attainment of goals.
5. to reduce pressure on sensitive areas and to
prevent development of problems with skin
integrity.

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Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 7

Nursing diagnosis #3: Activity intorlerance related to immobility as evidence by total right side weakness

Outcome(s):

Nursing interventions Scientific Rationales Evaluation

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Clinical Concept Map/Care Plan - Student Name: _________________________________________________ 8

Nursing diagnosis #4: Hopelessness r/t deteriotating physicological condition AEb ongoing stroke causing necrosis of the brain
tissue

Outcome(s): Recognize and verbalize feelings. Identify and use coping mechanisms to counteract feelings of hopelessness.

Nursing interventions Scientific Rationales Evaluation

1. Have client describe events that lead to
feeling inadequate or having no control.
2. Evaluate degree of hopelessness using
psychological testing such as Beck's
Depression Scale. Note client's feelings about
life not being worth living and other signs of
hopelessness and worthlessness
3. Explain all tests and procedures. Involve the
client in planning a schedule for care. Answer
questions truthfully.
4. Help the client begin to develop coping
mechanisms that can be used effectively.
1. Identifies sources of frustration and
defines problem areas so action can be
taken to deal with them in more positive
ways.
2. Identifying the degree of hopelessness and
possible suicidal thoughts is crucial to
instituting appropriate treatment to protect
client.
3. This enhances trust and therapeutic
relationship, enabling the client to talk freely
about concerns.
4. to counteract hopelessness.

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5. Descriptive text is not available for this 5. Necessary to evaluate effectiveness and
imageEmphasize the need for continued prevent or minimize possible side effects.
monitoring of medication regimen by
healthcare provider.

Nursing diagnosis #5:

Outcome(s):

Nursing interventions Scientific Rationales Evaluation

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References

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