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Student Name: Date: Complete the following: Nursing Assessment and clinical map.
2.As the day progresses, update assessment, diagnoses, interventions and outcomes.
3.Place an asterisk (*) by the priority nursing diagnosis and draw arrows to reflect
relationships.
4.Complete patient evaluations at the appropriate time.
5.Clinical Maps must reflect the care actually provided.
6.Use a highlighter to indicate additional interventions for your client.
7.Clinical Maps must be turned in one week after the clinical day.
Comments:
CLINICAL MAP
Nursing Diagnosis
Interventions: Evaluation:
1.) Teach and assess patient’s correct use of 1.) The patient verbalized understanding about
patient-controlled analgesia to ensure the use of the PCA pump.(M)
effectiveness in PACU and upon returning to 2.) The patient is satisfied with the relief of pain
the floor. controlled by the use of the PCA pump.(M)
2.) The nurse should use pain control
measures before pain becomes severe by
making sure patient is getting a high enough
dosage through the PCA pump.
3.) The nurse should assess pain for character,
location, and effectiveness of relief measures
every 4 hours.
Modifications in Plan of Care
The nurse will continue to monitor the patient for any changes and notify the physician if needed.