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Mr. Charles Lamont is a 45-year-old patient who is visiting his primary care physician for his an annual checkup. His wife is waiting for him in the lobby; she is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. Mr. Lamont works for a construction company as a heavy machine operator. He smokes 1½ packs of cigarettes per day. His wife has been encouraging Mr. Lamont to stop, but he has not showed any interest in quitting. Laura, the registered nurse, takes Mr. Lamont to an examination room. Laura asks him about his overall health and he tells her about a nagging cough and how he sometimes feels short of breath. He then denies any other health problems. Laura takes Mr. Lamont’s vital signs and gets the following results: blood pressure, 156/94 mm Hg; temperature, 99.8° F orally; apical pulse, 104 beats/min; respiration, 25 breaths/min and regular; and pulse oximetry, 95%.
Using the care map template given to you, create a care plan for this patient.
Please, upload just your care map here once completed. Your written care map paper will need to be uploaded as scheduled in Turnitin.
Individual Care Map Evaluation Tool
Name: _______________________ Date: ___________ Patient’s initials: _______________
(Follow instructions provided and on Moodle)
The student will:
Prepare: Written Analysis (50 pts) and Concept Map
Selects relevant objective and subjective assessment data for the client situation.
Organizes relevant data into objective and subjective data.(2)
Does not organize data.(1)
Demonstrate appropriate use of Gordon’s Functional Patterns by organizing data into meaningful data clusters to determine priority problem
Data cluster complete the support Gordon’s patterns selected (3)
Data clusters present, < 80% of relevant data uncluded, appropriate Gordon’s pattern selected (2.5)
Data clusters do not support Gordon’s pattern selected. (1)
Plans appropriate care for client:
· Goal statement
· Expected outcomes
Goal statement reflects resolution or reduction of priority problem identified. (2)
Client goal does not address the nursing diagnosis or Expected outcomes do not support goal achievement or are no written in SMART format. (0.5)
Plans appropriate care for client:
· Nursing interventions
· Clearly support interventions with one individualized EBP rationale per intervention and write a citation for each intervention.
3 or more nursing interventions listed address the cause of the problem and help the client achieve the goal use evidence based practice, individualized for the patient, each intervention has rationale with APA citation and reference. (20)
≤ 3 nursing interventions listed address the cause of the problem and help the client achieve the goal, use evidence based practice, each intervention has rationale with APA citation and reference. (18)
≤ 3 Interventions listed do not address the cause of the problem nor help the client achieve the goal, use evidence based practice, or not relevant for the patient, each intervention has rationale with APA citation and reference. (16)
Interventions(s) do not address the cause of the problem nor assist the client to achieve the goal with evidence based practice, Or rationale inappropriate for the selected interventions, each intervention has with APA citation and reference (10)
Interventions without rationale or APA citation and reference (0)
Use Care Map to plan client care
Format relevant Care Map: Patient is represented and data cues organized into data clusters which reveal
Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc. Indicates how each step in the nursing process affects the others, and is formatted logically. (10)
Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc. Does not indicate how each step in the nursing process affects the others; formatted logically. (9)
Does not originate from the client OR Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc. Indicates how each step in the nursing process affects the others, and is formatted logically. (7)
Data originates from the client. Two or more of the following is not present: Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc. Or Indicates how each step in the nursing process affects the others, Or is formatted logically. (5)
Does not originate from the client. Relationships between concepts are illogical or do not indicate cause/effect. Steps in nursing process not included. (2)
Total Points Available/ Student Points Earned:
Faculty signature: ______________________Student signature: __________________________
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