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**files (1)** – ## FrancisKanu_207.docx **## FrancisKanu_207.docx** Clinical Patient Clinical Judgement Concept Map  Assignment Instructions Choose one patient at clinical to complete a concept map. Paraphrase the patient…
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**files (1)**
– ## FrancisKanu_207.docx
**## FrancisKanu_207.docx**
Clinical Patient Clinical Judgement Concept Map

Assignment Instructions
Choose one patient at clinical to complete a concept map. Paraphrase the patient's history and physical data ensuring inclusion of the following information to create patient introduction data for the concept map:
History of Present Illness (HPI)
Age: In decades e.g 65 years should be 60s
Gender
Code status
Allergies
Isolation and precaution
VS on admission and date of care. Include POX and pain
Admitting diagnosis
Activity/Functional level
Bowel & Urinary elimination status
Skin integrity
Morse and Braden score
DVT prophylaxis
Labs: Na, K, a, C02, BUN, Creat, glucose, WBC, H/H, Platelet, PT, PTT, and INR
***Provide a minimum of 2 assessment data to support your top 3 prioritized problems
\*\*\*\* Look at the healthcare provider's assessment and plan under H & P or progress note and patient care orders for assessment and interventions data.
\*\*\* If any of the above requested data is not available in your patient's record, indicate unavailability Note posted concept map care plan guidelines and grading rubric.
Submission

Word count: 0

4/24/26, 2:45 PM
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| t BSSR |
| 579/579-A<br> <br>31 y.o, male<br>DOB: 10/25/1994<br>CSN: 1070237678<br>Code Status: FULL<br>Isolation: No active isolations<br>FALL RISK: HIGH<br><br>FALL RISK: Low<br>Height: 5' 8" (172.7 cm)<br>Weight: 213 1b (96.6 kg)<br>All Diet Orders Placed on Patient (72h ago,<br><br>onward)<br><br>None | Admit Date: 4/6/2026 Expected Discharge Date: <br><br>Amina Sadaft MD<br>Active Hospital Problems<br>Diagnosis<br>· Sacral wound, initial encounter<br>· Paraplegia (HCC)<br>· Neurogenic bladder<br>· Normocytic anemia<br>· Hypotension<br>· Infected wound e Pressure injury of skin with infection<br><br>What Matters to the Patient/Family?: healthy recovery<br>Allergies<br>Allergen<br>· Amoxicillin<br> | Apr 24, 2026<br>Date Noted 04/06/2026<br><br>04/06/2026<br>04/06/2026<br>04/06/2026<br><br>04/06/2026<br>04/06/2026<br> <br>04/06/2026<br><br>Reactions<br>Hives (Childhood) |
| Past Medical History:<br><br><br><br>Diagnosis<br>•Open wound of lower back and pelvis without penetration into retroperitoneum<br>•Paraplegia (HCC)<br>•Sacral wound, initial encounter | Date<br>02/25<br>/2026<br>04/06<br>/2026 | Active LDAs:<br>PICC Line 04/18/26 <br>Wound 04/07/26 <br>Incision 04/06/26 <br>Current Visit<br>Past Procedures <br><br>Date <br>04/06/2<br> <br>026<br>04/10/2<br>026<br>04/13/2<br>026<br>04/15/2<br>026 | 1330 Single-lumen basilic <br>sacral spine (Active)<br>1101 sacral spine (Active)<br>(4/6/2026 to Today)<br>SUBCUTANEOUS TISSUE, AND<br> <br>Procedures<br>MUSCLE, TORSO<br>EXCISION, PRESSURE ULCER,<br>SACRAL REGION – N/A<br>EXPLORATION, WOUND,<br>DELAYED PARTIAL CLOSURE<br>AND WOUND VAC PLACEMENT – N/A<br>EXPLORATION, PRESSURE<br>ULCER, SACRAL REGION N/AAPPLICATION OR<br>REPLACEMENT,WOUND VAC N/A | vein, right 4 Fr (Active)<br>Providers<br><br><br><br> | |  |
Printed by Wesla Taylor, RN [WTAYLOR2] 4/24/2026 2:45 PM 1/2
Wesla list – Last Refreshed: 04/24/26 1445
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| — | — | — | — | — | — | — | — | — | — | — | — |
| | Room• | | Patient Name/Age/Sex | Code<br>Status | | Problem | Pain POSS Due Icon | Diet Orders | | Tx Team Sticky Note<br>MEDICAL/SURGICAL | Blank Column |
| | 79 | | C (31 yo. M) | Full Code | | Sacral wound, initial encounter | | Diet Regular | | /6- ED from Encompass with c/o Sacral wound infection<br>-OR: Debridement of Sacral Wound<br>4/7- ID cls – IVABX adjusted, wound cx (+)l WORN orders in<br>4/8- OT reccs ARF; refusing labs<br>4/9 WBC 11; more necrosis found in sacrum – NPO @ mn, RTOR in am for debridement of sacral wound 4/10 OR excision of sacral wound; advanced to regular diet. Need SW cons for counseling resources? 4/12: pt declined PICC until later date<br>4/13: RTOR wound vac placement<br>4/15 Plan for OR, wound vac exchange, refused AM labs<br>4/16: pt declined PICC d/t risks<br>-Plan for bedside debridement 4/17<br>-Ethics consulted<br>-Plan for family discussion Monday 4/20<br>4/18: PICC placed<br>4/20 Family wound teaching<br>4/22: d/c home w/mom w/home health, IV abx, wound vac and straight cath. Needs SOC<br>/23: hypotensive 60s/40s MAP 500cc bolus xl -lactate 1.0<br>Care notes:<br>IVFAbx, Reg, straight cath q6, midodrine TID, Wvac Hx: C7 paraplegic (recent MVA 2/25126 w/ spinal cord injury s/p corpectomy w/ anterior C7, C6-TI anterior cervical discectomy/fusion and C2-T3 posterior cervical dissection(fusion), recently dx UTI 4/4 EDD TBD | |
| | 80 | | Holcomb, R (81 y.o. M) | Full Code | | Osteomyelitis of right foot (CMS/HCC) (HCC) | | Diet<br>Cardiac/Carb controlled | | SURGICAL (PODIATRY)<br>/15 OR: Partial excision of first metatarsal of right foot & wound closure<br>4/16 PT/OT rec SAR, needs placement<br>117: AL Cherry Lane – may have bed open tomorrow<br>4/18: ID consulted – Abx zosyn, path pending<br>- restart coumadin<br>4/21 : waiting for bed<br>Care notes:<br>NWB<br>Hx: afib, DM<br>EDD: TBD end ath & lacement | |

Page 1 of 2 Printed by Wesla Taylor on 4/24/26 2:45 PM
Recognize Cues (Assessment) Identify all relevant subjective (0-10 points) and objective assessment information related to the client's condition (0-10 points)
20 possible points (20%)
 Analyze Cues (Analysis)- Form hypotheses
Based upon assessment information, identify, and prioritize the top 3 client problems. In
other words, which 3 assessment findings are of immediate concern? (0-9 points) Below each client problem, determine and enter 2 relevant assessment information that supports the identified client problem. (0-9 points)
18 possible points (18%)
. Prioritize Hypotheses (Analysis) Identify with rationale the assessment findings that the
nurse should address first (0-6 points) State priority framework used for the identification (0-3) and rationale for choice (0-3 points)
12 possible points (12%)
 Generate Solutions (Planning) What is the desirable client outcome(s)? State 2 outcomes (0-4 points) Identify 3 possible nursing interventions that can be done for the prioritized problem. (0-9 points) State rationale for each intervention (0-3 points) SMART
criteria met for outcomes and interventions (O4 points)
20 possible points (20%)
Take Action (Implementation) Prioritize with rationales the 3 actions the nurse should take to address the priority assessment finding? (0-9 points) What 2 client factors must you consider when making this decision? (0-4 points) How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)? (0-5 points)
18 possible points (18%)
Evaluate Outcomes (Evaluation) – Outcome met with qualifying statement (0-3 points) Outcome partially met with qualifying statement (0-3 points) -Outcome not met with qualifying statement (0-3 points) What additional interventions or assessments should the nurse implement if expected outcome(s) are partially met or not met? (0-3 points)
12 possible points (12%)
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**## FrancisKanu_207.docx**
Clinical Patient Clinical Judgement Concept Map

Assignment Instructions
Choose one patient at clinical to complete a concept map. Paraphrase the patient's history and physical data ensuring inclusion of the following information to create patient introduction data for the concept map:
History of Present Illness (HPI)
Age: In decades e.g 65 years should be 60s
Gender
Code status
Allergies
Isolation and precaution
VS on admission and date of care. Include POX and pain
Admitting diagnosis
Activity/Functional level
Bowel & Urinary elimination status
Skin integrity
Morse and Braden score
DVT prophylaxis
Labs: Na, K, a, C02, BUN, Creat, glucose, WBC, H/H, Platelet, PT, PTT, and INR
***Provide a minimum of 2 assessment data to support your top 3 prioritized problems
\*\*\*\* Look at the healthcare provider's assessment and plan under H & P or progress note and patient care orders for assessment and interventions data.
\*\*\* If any of the above requested data is not available in your patient's record, indicate unavailability Note posted concept map care plan guidelines and grading rubric.
Submission

Word count: 0

4/24/26, 2:45 PM
| | | | | |
| — | — | — | — | — |
| | | | | | |
| — | — | — | — | — |
| t BSSR |
| 579/579-A<br> <br>31 y.o, male<br>DOB: 10/25/1994<br>CSN: 1070237678<br>Code Status: FULL<br>Isolation: No active isolations<br>FALL RISK: HIGH<br><br>FALL RISK: Low<br>Height: 5' 8" (172.7 cm)<br>Weight: 213 1b (96.6 kg)<br>All Diet Orders Placed on Patient (72h ago,<br><br>onward)<br><br>None | Admit Date: 4/6/2026 Expected Discharge Date: <br><br>Amina Sadaft MD<br>Active Hospital Problems<br>Diagnosis<br>· Sacral wound, initial encounter<br>· Paraplegia (HCC)<br>· Neurogenic bladder<br>· Normocytic anemia<br>· Hypotension<br>· Infected wound e Pressure injury of skin with infection<br><br>What Matters to the Patient/Family?: healthy recovery<br>Allergies<br>Allergen<br>· Amoxicillin<br> | Apr 24, 2026<br>Date Noted 04/06/2026<br><br>04/06/2026<br>04/06/2026<br>04/06/2026<br><br>04/06/2026<br>04/06/2026<br> <br>04/06/2026<br><br>Reactions<br>Hives (Childhood) |
| Past Medical History:<br><br><br><br>Diagnosis<br>•Open wound of lower back and pelvis without penetration into retroperitoneum<br>•Paraplegia (HCC)<br>•Sacral wound, initial encounter | Date<br>02/25<br>/2026<br>04/06<br>/2026 | Active LDAs:<br>PICC Line 04/18/26 <br>Wound 04/07/26 <br>Incision 04/06/26 <br>Current Visit<br>Past Procedures <br><br>Date <br>04/06/2<br> <br>026<br>04/10/2<br>026<br>04/13/2<br>026<br>04/15/2<br>026 | 1330 Single-lumen basilic <br>sacral spine (Active)<br>1101 sacral spine (Active)<br>(4/6/2026 to Today)<br>SUBCUTANEOUS TISSUE, AND<br> <br>Procedures<br>MUSCLE, TORSO<br>EXCISION, PRESSURE ULCER,<br>SACRAL REGION – N/A<br>EXPLORATION, WOUND,<br>DELAYED PARTIAL CLOSURE<br>AND WOUND VAC PLACEMENT – N/A<br>EXPLORATION, PRESSURE<br>ULCER, SACRAL REGION N/AAPPLICATION OR<br>REPLACEMENT,WOUND VAC N/A | vein, right 4 Fr (Active)<br>Providers<br><br><br><br> | |  |
Printed by Wesla Taylor, RN [WTAYLOR2] 4/24/2026 2:45 PM 1/2
Wesla list – Last Refreshed: 04/24/26 1445
| | | | | | | | | | | | |
| — | — | — | — | — | — | — | — | — | — | — | — |
| | Room• | | Patient Name/Age/Sex | Code<br>Status | | Problem | Pain POSS Due Icon | Diet Orders | | Tx Team Sticky Note<br>MEDICAL/SURGICAL | Blank Column |
| | 79 | | C (31 yo. M) | Full Code | | Sacral wound, initial encounter | | Diet Regular | | /6- ED from Encompass with c/o Sacral wound infection<br>-OR: Debridement of Sacral Wound<br>4/7- ID cls – IVABX adjusted, wound cx (+)l WORN orders in<br>4/8- OT reccs ARF; refusing labs<br>4/9 WBC 11; more necrosis found in sacrum – NPO @ mn, RTOR in am for debridement of sacral wound 4/10 OR excision of sacral wound; advanced to regular diet. Need SW cons for counseling resources? 4/12: pt declined PICC until later date<br>4/13: RTOR wound vac placement<br>4/15 Plan for OR, wound vac exchange, refused AM labs<br>4/16: pt declined PICC d/t risks<br>-Plan for bedside debridement 4/17<br>-Ethics consulted<br>-Plan for family discussion Monday 4/20<br>4/18: PICC placed<br>4/20 Family wound teaching<br>4/22: d/c home w/mom w/home health, IV abx, wound vac and straight cath. Needs SOC<br>/23: hypotensive 60s/40s MAP 500cc bolus xl -lactate 1.0<br>Care notes:<br>IVFAbx, Reg, straight cath q6, midodrine TID, Wvac Hx: C7 paraplegic (recent MVA 2/25126 w/ spinal cord injury s/p corpectomy w/ anterior C7, C6-TI anterior cervical discectomy/fusion and C2-T3 posterior cervical dissection(fusion), recently dx UTI 4/4 EDD TBD | |
| | 80 | | Holcomb, R (81 y.o. M) | Full Code | | Osteomyelitis of right foot (CMS/HCC) (HCC) | | Diet<br>Cardiac/Carb controlled | | SURGICAL (PODIATRY)<br>/15 OR: Partial excision of first metatarsal of right foot & wound closure<br>4/16 PT/OT rec SAR, needs placement<br>117: AL Cherry Lane – may have bed open tomorrow<br>4/18: ID consulted – Abx zosyn, path pending<br>- restart coumadin<br>4/21 : waiting for bed<br>Care notes:<br>NWB<br>Hx: afib, DM<br>EDD: TBD end ath & lacement | |

Page 1 of 2 Printed by Wesla Taylor on 4/24/26 2:45 PM
Recognize Cues (Assessment) Identify all relevant subjective (0-10 points) and objective assessment information related to the client's condition (0-10 points)
20 possible points (20%)
 Analyze Cues (Analysis)- Form hypotheses
Based upon assessment information, identify, and prioritize the top 3 client problems. In
other words, which 3 assessment findings are of immediate concern? (0-9 points) Below each client problem, determine and enter 2 relevant assessment information that supports the identified client problem. (0-9 points)
18 possible points (18%)
. Prioritize Hypotheses (Analysis) Identify with rationale the assessment findings that the
nurse should address first (0-6 points) State priority framework used for the identification (0-3) and rationale for choice (0-3 points)
12 possible points (12%)
 Generate Solutions (Planning) What is the desirable client outcome(s)? State 2 outcomes (0-4 points) Identify 3 possible nursing interventions that can be done for the prioritized problem. (0-9 points) State rationale for each intervention (0-3 points) SMART
criteria met for outcomes and interventions (O4 points)
20 possible points (20%)
Take Action (Implementation) Prioritize with rationales the 3 actions the nurse should take to address the priority assessment finding? (0-9 points) What 2 client factors must you consider when making this decision? (0-4 points) How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)? (0-5 points)
18 possible points (18%)
Evaluate Outcomes (Evaluation) – Outcome met with qualifying statement (0-3 points) Outcome partially met with qualifying statement (0-3 points) -Outcome not met with qualifying statement (0-3 points) What additional interventions or assessments should the nurse implement if expected outcome(s) are partially met or not met? (0-3 points)
12 possible points (12%)
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