CURRENT MEDICAL DIAGNOSIS: Bipolar Personality Disorder

DEFINITION OF CURRENT MEDICAL DIAGNOSIS: Mental disorder !arateri"ed #y alternation o$ %ani and depressi&e states
SOURCE: '''' Essentials o$ Psy!iatri Mental (ealt! N)rsin* + ,
nd
ed- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
PAT(OP(.SIOLOG.:
Bipolar re$ers to t!e e/periene o$ #ot! poles o$
%ood: %ania and depression- People
0it! Bipolar Disorder1 $or%erly alled manic-
depressive disorder 1 !a&e e/periened at least one
%ani episode or one %i/ed %ood episode 20it!
rapid ylin* o$ depression and %ania in t!e sa%e
day3- Us)ally t!ese indi&id)als !a&e also
e/periened one or %ore %a4or depressi&e
episodes- O&erall1 %ost people
0it! #ipolar disorder e/periene %ore depressi&e
t!an %ani episodes- A %ani episode is a distint
period o$ a#nor%al and persistently ele&ated1
e/pansi&e1 or irrita#le %ood1 lastin* at least 5
0ee6- T!e %ood dist)r#ane is s)$$iiently se&ere
to a)se %ar6ed i%pair%ent in o)pational
$)ntionin* or relations!ips 0it! ot!ers or to
neessitate !ospitali"ation to pre&ent !ar% to sel$
or ot!ers- First episode )s)ally in ,78s1 a$$etin*
0o%en and %en e9)ally- : Types: Bipolar I1
Bipolar II1 (ypo%ania1 Bipolar NOS-
ETIOLOG.:
CLINICAL MANIFESTATIONS
2Si*ns ; Sy%pto%s3:
Mani: elation1 e)p!oria1 )n)s)ally *ood- Constant1
indisri%inate ener*y and ent!)sias%- Alternates
#et0een elation and irrita#ility-
Grandiose del)sions< #elie&in* lient is $a%o)s or a
s)per!ero- Dereased need $or sleep- A0a6e !o)rs
earlier t!an )s)al $eelin* alert and ener*eti- Rapid
and press)red spee!- Disor*ani"ed1 rapid t!o)*!ts-
Easily distrated- Poor 4)d*%ent- May !a&e
!all)inations-
Indeisi&e1 e/essi&e=onstant %otor ati&ity1 poor
n)trition1 lo)d1 !ostile1 ra*e reations- Manip)lati&e1
an*ry1 i%p)lsi&e- Rain* t!o)*!ts1 pro&oati&e
#e!a&iors-
LAB=RADIOGRAP(IC FINDING USUALL.
PRESENT:
MEDICAL MANAGEMENT
2Inl)de Treat%ents ; Mediations3:
Antidepressants *i&en 0it! eit!er lit!i)% or
di&alproe/ !a&e #een e$$eti&e- Mood
sta#ili"ers 2anti%ani a*ents31 antion&)lsants
2%ood sta#ili"ers31 #en"os1 antipsy!otis-
Psy!ot!erapy1 )s)ally d)rin* re%issions so
lients are onentratin* properly- Gro)p
t!erapy 0!en t!e a)te p!ase o$ %ania or
depression !as passed- Monitor !ydration< 6eep
0ell !ydrated- Get s)$$iient sleep=rest-
Sel)sion or restraints i$ patient is dan*ero)s-
Meds: Lit!i)%1 Depa6ote1 Te*retol1 La%ital1
>lonopin1 Ati&an1 Sy%#ya/-
ECT $or se&ere %ani #e!a&ior 2s)iidal1 no
reation to lit!i)%1 rapid ylin*3-
DISC(ARGE PLANNING
2Client Ed)ation3:
Sy%pto%s o$ i%pendin* episodes1 s)! as
5
T!e #rain ne)rotrans%itters norepinep!rine and
dopa%ine are i%pliated in t!e a)se o$ %ani
episodes- T!e sa%e %onoa%ine ne)rotrans%itters
0!ose dereased ati&ity is i%pliated in
depression are inreased in %ania- (or%ones also
interat 0it! ne)rotrans%itters in %ood disorders-
(ypot!yroidis% is orrelated 0it! depression and
0it! rapid ylin* o$ %ood #et0een depression
and %ania- Any *i&en %ani episode is li6ely to
$ollo0 a stressor- Disordered sleep 2s)! as
e/periened 0!en tra&elin* aross ti%e "ones or
0or6in* t!e ni*!t s!i$t3 %ay #e a tri**er-

''''''''''''''''''
Mood Disorder ?)estionnaire $or sreenin*-
C!arateristis o$ %an)a and depressi&e %oods
o#ser&ed- Cyles o$ depression=%ania present 0it!
possi#le periods o$ nor%al $)ntion in #et0een-
Aordin* to DSM1 at least @ riteria %)st #e %et:
!yperinso%nia1 e/essi&e tal6in*1 $li*!t o$ ideas1
distrated easy1 ris6 ta6in* ati&ity in&ol&e%ent
e/essi&ely-

!an*es in sleep pattern- Esta#lis! re*)larity in
sleepin*1 eatin*1 e/erise- Li$e<lon* need $or
%ood sta#ili"er- E/peted side e$$ets o$
%ediations &s to/i side e$$ets- Stay a0ay
$ro% alo!ol1 dr)*s1 a$$eine1 so%e OTC %eds-



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 Stage: 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
"y patient is really struggling with this stage right now She may have previously met it! but now is having trouble She is unable to be completely
independent and reports having trouble with everyday tasks such as grocery shopping! paying bills! and even cooking She has a lot of trouble coping
and has fre#uent episodes of mania $ depression brought on by the extra stress of personal situations at home
Erickson
"aturity: %& and over ' (ntegrity vs )espair- *cceptance of worth and uni#ueness of one+s own life *cceptance of death ,EG*-(.E: Sense of loss!
contempt for others
She has definitely met the negative resolution of this stage She repeatedly spoke about being depressed and angry She felt a sense of loss because
of her husband+s accident and current health She commented on feeling lonely and not having friends or family nearby She was overwhelmed with
responsibilities and has definitely not shown signs of acceptance of her own worth
Piaget
Formal /peration Phase: 00 to 0& ' 1ses rational thinking 2easoning is deductive and futuristic
-his patient is currently not meeting this stage appropriately while in the hospital She does not think rationally! even aside from her hallucinations She
has a diagnosis of bi-polar disorder! which most definitely affects her thinking and reasoning 3er priority is her pain and she only cares about making it
go away! not how it oes away She asked for drugs and stated it would make everything better She has high anxiety and a history of depression
BRAINSTORMING LISTS
@
O#4eti&e Data S)#4eti&e Data N)rsin* Dia*noses
2All yo) an t!in6 o$3
MRI: Coaine a#)se Ris6 $or In4)ry
Poor inspiratory e$$ort ABre6ed ar a$ter %edsC Ris6 $or Diolene
S)#se*%ental Ateletasis ATal6in*=seein* sel$ at !o%eC Dist)r#ed T!o)*! Proess
C> ,:@ 2(3 ADepressedC EDist)r#ed Sensory Pereption
A<$i#: No P Ba&e ATossin* ; t)rnin* all ni*!tC I%paired Soial Interation
Fli*!t o$ ideas Li&es alone Inso%nia
Constant %o&e%ent No $a%ily s)pport=!elp EInterr)pted Fa%ily Proesses
(/: COPD Tro)#le ad4)stin* F !o%e Ati&ity Intolerane
Depression Di$$- ta6in* on ne0 responsi#ilities EAn/iety
DDD I%paired Co%$ort
Bea6 Dist)r#ed Ener*y Field
Br)isin* on $ae=ar%s=le*s Ris6 $or Falls
E!y%osis I%paired Gas E/!an*e
A*itated easily EC!roni Pain
E/essi&e tal6in* EDist)r#ed Sleep Pattern
Soial Isolation
EI%paired (o%e Maintenane
Altered Tiss)e Per$)sion
:
LA3O4ATO41 DATA
LA3 TESTS DATES5 45& 456 -rend INTE4P4ET 4ESULTS 6 SI7NIFICANCE TO PT
278 'slightly low! but this may be the norm for this patient
3gb- slightly low! possibly due to nutritional deficiency
3ct-slightly low! possibly low d5t nutritional deficiency
TIME 9:;& <<0&
TEST NAMES NO4MAL 4AN7E
C3C
=78 ;: ' 009 6; &6
Platelets 0&9 ' 699 <9: <;4
278 690 ' 649 ;>0 ? ;>9 ?
3gb 0<& ' 064 0<9 ? 00: ?
3ct ;&> ' 6:4 ;&% ? ;&& ?
3MP
,a@ 0;6 ' 066 0;> 0;< ?
71,- low d5t possibly not eating enough protein while in the
hospital
Glucose- high d5t stress or inAury from her fall Bacute stressC
D@ ;& ' &< ;4 ;&
8(- 4: ' 09> 09& 44
71, > ' <: : ? 4
8reatinine 9&: ' 099 9:& 9>;
8/< <9 ' ;< <& <<
Glucose %& ' 44 46 0&& 3
Clotting
Factors
(.e$atolog!-
P-
P--
(,2
Sed 2ate
Misc%
.e$atologies
8PD
-roponin
Li"er F*nction
Tests
(Che$istr!-
- 7ilirubin
*lk Phos <& ' 0%& 9<
SG/- 9 ' 69 <0
*lbumin ;% ' 6> 6&
Misc%
Che$istries
8a@ >% ' 09< 4; 4;
"g@ 0%9 ' <%9 <0; <9<
Phosphorus
1ric *cid
-otal Protein
A37
p3
P8/<
38/;
P/<
Other8
(List Na$e
an Nor$al
4ange-
7ld 8ulture
71,58r 2atio- low d5t possibly not enough protein intake! or
low-protein high-carb diet
8D $ 8D"7 high d5t possible trauma and inflammation of the
heart muscles from her falls and poor heart health
1rine8ulture
1rinalysis
71,58r 2at 009 ' <%9 4; ? 09> ?
8D <6 ' 0:; 0:9 <6; 3
8D "7 99 ' <4 &>9 3
G
DIA7NOSTIC TESTS
8hest E-2ay B)ates $ 2esultsC
45&506 F 9><6:
"inimal residual bibasilar subsegmental
atelectasis Poor inspiratory effort
SignificanceG
2ules out infection as cause of altered mental
status 3eart is normal
EDG B)ates $ 2esultsC Significance G
/ther 2adiographic Studies B)ates $
2esultsC
"2( 3ead )=( /nly 45&506 F 00&6:
,o region of restricted diffusion is identified to
suggest acute infarction
SignificanceG
,o evidence of heart attack as cause of *-
fib5irregular 32
/ther )iagnostic -ests- B)ates $ 2esultsC
8- 3ead =5o (. 8ont 456506 F <<&& :
,o abnormalities on noncontrast 8- brain
with bone windows ,o interval change
Significance G
,o apparent damage to head5brain from falls
at home
H
CU44ENT MEDICATIONS 9O4:S.EET
T4ADE;7ENE4IC
NAMES
DOSE
O4DE4ED
AND
4OUTE
TIME
7IVEN
CLASSIFICATION
AND ACTION
DOSA7E
4AN7E
4ATIONALE FO4
ADMINIST4ATION
SIDE
EFFECTS
NU4SIN7
IMPLICATIONS
)iltiaHem
8ardiHem
;9 mg P/
7()
9499
<099
8alcium 8hannel
7locker:
(nhibits transport of
8a into heart muscle
cells! decreasing
excitability of the heart
contractions
;9-0<9 mg
;-6 times
daily 1p to
;%9 mg5day
2eduction of
ventricular rate in a-
fib *lso causes
systemic vasodilation!
lowering 7P
*rrhythmias
3F! SIS!
peripheral
edema
"onitor ($/! assess for 3F
*ssess for SIS rash 2eport
32 J &9 bpm
Protonix
PantopraHole
69 mg P/
K*"
9499
Proton Pump (nhibitor:
7inds to enHyme in
acidic p3! preventing
final transport of 3@
ion into gastric lumen
69 mg daily GE2) Pseudome
mbranous
colitis
"onitor bowel function Bfor
P8C )o not crush tabs
*void alcohol and ,S*()s
*spirin E8
;<& mg
K*"
9499
*ntipyretic5,onopioid!
Salicylate:
)ecrease platelet
aggregation Produce
analgesia! reduce
inflammation
1p to
6g5day
2elieve pain and
inflammation from
)))
G( bleeding!
anaphylaxis
! laryngeal
edema
"onitor liver function for
toxicity Prolongs bleeding
time "onitor 3$3
periodically to assess for G(
bleed -ake with water *void
alcohol
?ovenox
Enoxaparin
)58+d 45:
69 mg SK
)aily
9499
*nticoagulant:
Potentiates inhibitory
effect of antithrombin
on thrombin
0& mg5kg
daily
Prevention of ).-
while in hospital
7leeding!
anemia
*ssess for signs of bleeding
/bs for hematoma 3old if
platelets J 099
.it );
8holecalciferol
<!999 units
)aily
9499
.itamin Bfat-solubleC:
Promotes absorption
of 8a 2e#uires
activation in liver $
kidney to create active
form of .it );
699-099 (1
daily
-reatment5Prevention
of 8a! for )))
Pancreatitis /bserve for hypocalcemia
"onitor for toxicity
Bhypercalcemia! hyperphos!
hypercalciuriaC
,eurontin
Gabapentin
0<99 mg
P/ -()
9499
<099
*nticonvulsant5"ood
StabiliHer:
1nkwn "ay affect
amino acid transport
across neuronal
membranes
>-;&
mg5kg5day
in ; divided
doses
-reatment of 7ipolar
disorder! anxiety
Suicidal!
rhabdomyol
ysis!
multiorgan
hypersensiti
vity
"onitor for suicidal thoughts
"onitor mood for
depression
I
U44ENT MEDICATIONS 9O4:S.EET
T4ADE;7ENE4IC
NAMES
DOSE
O4DE4ED
AND
4OUTE
TIME
7IVEN
CLASSIFICATION
AND ACTION
DOSA7E
4AN7E
4ATIONALE FO4
ADMINIST4ATION
SIDE
EFFECTS
NU4SIN7
IMPLICATIONS
"ultivitamin
0 tab P/
daily
9499
.itamin:
2eplaces vitamins
"ay act as catalyst in
metabolic functions
0 tablet
daily
-o prevent5treat low
vitamin levels
1rine
discoloratio
n! ,5.
*ssess for signs of
nutritional deficit
Sucralfate
8arafate
0 g P/ 7() 9499
<099
*nti-1lcer:
*luminum salt reacts
with gastric acid and
forms white paste that
protects ulcer
0 G 7()! 0
hr before
meals
Protect5Prevention of
ulcers
8onstipatio
n!
anaphylaxis
Empty stomach! 0 hour
before meals (ncrease fluids
to prevent constipation
-opiramate
-opamax
&9 mg P/
7()
9499
<099
"ood StabiliHer:
Enhancement of
G*7*! prevention of
activation of excitatory
receptors! block 8a
channels in neurons
<&-<99 mg
7()
-reatment of bipolar
disorder
SeiHures!
suicidal!
drowsy!
abnormal
vision
"onitor for behavior
changes "ay cause
anemia "onitor platelets
"onitor ?F- may increase
*?-5*S-
7upropion E?
=ellbutrin E?
6&9 mg P/
)aily
9499
*ntidepressant:
)ecreases neuronal
reuptake of dopamine
)iminish uptake of
serotonin $ norepi
0&9-699 mg
daily
-reatment of
depression
SeiHures!
suicide!
agitation!
dry mouth
"onitor mood *void
bedtime dose "ay impair
Audgment
)ocusate
8olace
099 mg P/
7()
9499
<099
Stool softener:
Promotes
incorporation of water
into stool $ secretion
into colon
&9 ' 699
mg in 0-6
divided
doses
Softening of stool 8ramps )o not crush *ssess bowel
function $ sounds Give with
full glass of water
*mitriptyline
Elavil
<& mg P/
)aily
9499
-ricyclic
*ntidepressant:
Potentiates effects of
serotonin $ norepi
1p to 0&9
mg daily
)epression $ *nxiety Suicidal!
*rrhythmias
! -orsade de
pointes!
sedation
*void use of SS2(+s
(ncrease 8,S depressants
"onitor mental status <
=eeks to work
J
CU44ENT MEDICATIONS 9O4:S.EET
T4ADE;7ENE4IC
NAMES
DOSE
O4DE4ED
AND
4OUTE
TIME
7IVEN
CLASSIFICATION
AND ACTION
DOSA7E
4AN7E
4ATIONALE FO4
ADMINIST4ATION
SIDE
EFFECTS
NU4SIN7
IMPLICATIONS
,orco
*cetaminophen5
3ydrocodone
09-;<& mg
0-< tabs
P/ K63
P2, pain
?ast
dose:
45% F
0>90
/pioid *nalgesic:
7ind to opiate
receptors in the
8,S 8,S
depression
<&-09mg
K;-%hr
,o more
than 6g
-ylenol in
<6 hours
8hronic Pain ?ow 7P!
sedation!
constipati
on!
dyspepsia
*ssess .S before 3old
for 22 J09 *ssess
bowel function! pain!
dependence
)iaHepam
.alium
09 mg P/
7()
P2,
*nxiety
?ast
dose:
45% F
9069
7enHo:
)epress 8,S by
potentiating
G*7* Skeletal
muscle relaxes
<-09mg <-
6x5day
*nxiety 2elief 2esp
)epressio
n! )rowsy
"onitor .S!
dependence *ssess
"S! sedation
(ncreased 25F falls
K
4O9AN<CA3A44US COMMUNIT1 COLLE7E
NU4SIN7 P4O74AMS
NU4 ==>;>==A3 Criteria for E"al*ation of Conce#t Ma##ing an Scoring 4*2ric
4e"ise ?>;=@;=A
Criteria E&e$#lar! Satisfactor! Nees I$#ro"e$ent Unsatisfactor! Score
-he following criteria will be used to evaluate
student performance of competencies related to
concept mapping
B POINTS
=% E&cees
e&#ectations as
o*tline in the
learning acti"it!
criteria%
>% Consistentl! oes
all or al$ost all of
the following8
C POINTS
=% Meets
e&#ectations 2! f*ll!
aressing the
learning acti"it!
criteria%
>% Does $ost or
$an! of the
following8
= 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
following8
? POINTS
=% Does not $eet
e&#ectations 2ase
on the learning
acti"it! criteria%
>% The assign$ent is
not s*2$itte%
C% Consistentl! oes
all or al$ost all of
the following8
I% Clinical Pre#;Pre<Clinical Manager Data8
U#ate Sections as A##lica2le on Da! >
0 Sim8hart Pre-8linical "anager includes
diagnosis section
< Sim8hart /rder EntryLgeneral orders
include activity and mobility! alerts! code
statusM nutrition orders Bdiet and fluidsC
; Sim8hart *dmission 3istory completed in
Patient 8harting section Ball areasC
6 Pathophysiology sheet is complete
according to assigned text sources $
relevant to client admission
& )evelopmental status notes Erikson!
Freud! Piaget stages! expected tasks! $
how client meets in hospital
H- ?ab and diagnostic test sheets completed
with interpretation of results for individual
client
a% All areas are
co$#letel! an
acc*ratel! recore
with *#ates note
2% Ientifies all la2
an;or iagnostic
res*lts for s#ecific
client
a% So$e areas are
not aresse, no
*#ates are note
2% Ientifies all
a2nor$al la2 an;or
iagnostic res*lts
for s#ecific client
a% Inacc*ratel!
recors an;or
$isinter#rets ata
2% Inacc*ratel!
recors an;or
$isinter#rets la2
an iagnostic
res*lts for s#ecific
client
a% Fails to re#ort #re<
clinical ata
2% Fails to ientif!
la2 an;or
iagnostic res*lts
for s#ecific client
57
II% Plan of Care Ma#;N*rsing Process For$at
an Content8
0 N7rainstormingO section complete with list of
obAective and subAective clinical
manifestations and complete list of
potential nursing diagnoses individualiHed
for assigned client
< "ap is created on clean! unruled BblankC
white paper
; *ssessment data is complete and
integrated into the plan of care map
6 -eaching Plan is outlined in detail on back
of plan of care map
& *ll concepts are enclosed inside a symbol
or shape
% ,ursing diagnoses are numbered
according to priority
: 7oth subAective and obAective data are
provided
> Each nursing diagnosis includes an
etiology Br5t! brief explanation of pathophysC
and clinical manifestations B*"7! signs!
symptomsC
4 -he meaning of relationships within
concepts is indicated by connecting lines
with linking words or abbreviations Br5t!
amb! patient will! nurse will! etcC
09 Goals and outcomes are measurable
00 Stated nursing care is appropriate for
specific client
0< )ata from the initial assessment is listed in
black
0; /ngoing assessment as collected is listed
in red
06 Shapes or symbols are outlined using the
8oncept "ap 8olor Dey
0& -he plan of care is legible
0% *ssessment data is integrated into the
concept care map
0: 8ross-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 (B-
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 B
a##ro#riate;#riorit!
n*rsing iagnosis
a% Correctl!
#rioriti/es highest
#riorit! iagnosis
2*t incorrectl!
n*$2ers others
2% (entifies three (C-
or $ore
relationshi#s
2etween conce#ts
c% So$e re"isions
are $ae
% ientifies B
a##ro#riate;
#riorit! n*rsing
iagnosis
a% Incorrectl!
#rioriti/es all
n*rsing iagnosis
2% Ientifies less
than three (C-
relationshi#s
2etween conce#ts
c% Few re"isions are
$ae
% ientifies few than
B a##ro#riate;
#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
$ae
% Fails to ientif!
a##ro#riate;#riorit!
n*rsing iagnosis
DDDDDD
55
III% Doc*$entation8 (Incl*es Si$Chart an;or
.os#ital Co$#*ter Charting-8
0 Systems *ssessment data are complete
and accurate for each day of care 7raden
scale and "orse Fall Scale completed
< .ital Signs are accurately recorded daily
; =ounds! drains5 tubes! ostomies recorded
daily as applicable
6 (ntravenous fluids and related data are
recorded daily B($/ sectionC
& (. and (nAection sites are recorded daily
% -reatment information is listed daily
: )iet5fluids and appetite data and
elimination data are recorded daily BP
eaten and ($/! 7"s recordedC
> Psychosocial5cultural data is complete
4 7asic ,ursing 8are is complete and
accurate BdailyC
09 *pplicable nursing interventions for each
listed body system are accurately recorded
BdailyC
00 Patient -eaching is recorded daily
0< )ischarge Planning section completed
0; ,arrative physical assessment notes are
clear! concise! factual! accurate! complete!
current! and organiHed
06 8orrect 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$$ents are well<
written, an client
s#ecific, acc*ratel!
reflecting client
stat*s%
b On Da! >,
oc*$ents well<
written, client
s#ecific narrati"e
#h!sical assess$ent
note that
e$onstrates
e&ce#tional ecision
$a'ing an
acc*ratel! reflects
client stat*s%
a% Doc*$ents Da! =
assess$ents an
client care
inter"entions in
Si$Chart% As
narrati"e co$$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$onstrate%
DDDDD
IV% Self<E"al*ation
0 Student completed self-evaluation using N-he
8offeehouseO on 7lack7oard
< Student followed directives given for )iscussion
7oard for current clinical week
; Student responded to at least < peers each
week with a constructive and supportive
comment
a% Thoro*gh an
insightf*l
co$#letion of all
reE*ire$ents of the
self<e"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$$ents
a% St*ent
co$#lete all
reE*ire$ents of the
self<e"al*ation #iece
of the r*2ric
2% St*ent
res#one to >
st*ents with
constr*cti"e an
s*##orti"e
co$$ents
a% St*ent i not
co$#lete all
reE*ire$ents of the
self<e"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 self<
e"al*ation
2% St*ent i not
res#on to an!
st*ents
DDDDDD
DDDDD
TOTAL SCO4E
5,
CONCEPT MAP :E18

Nursing
Diagnosis

Green


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

Lin'ing Line Arrow Cross<Lin' Line Arrow Lin'ing 9ors
(3lac'- (4e- (Pencil-
Instr*ctor Co$$ents8
-he Student must score a minimum of N;O to achieve competency for the assignment
-otal Score QQQQQQQQQQQQQQ divided by N09 O to get the Assign$ent Score F DDDDDDDDDDDDDDDDDD
Unsatisfactor! E"al*ation 4e#orte to the Clinical Co<coorinator on DDDDDDDDDDDDD%
S#ecif! 4e$eiation for Score Less Than C an D*e Date ($*st 2e #rior to ne&t clinical assign$ent-DDDDDDDDDDDDDDD%
QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ QQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQQ
(nstructor+ Signature )ate Student+s Signature )ate
5@