Concept Map Student: Date: Patient Demographic Data Initials: A.G Culture: Latina Instructor: Agency/Unit: Age: 21 Religion: Catholic Relevant Patient Data Admitting Diagnosis: Schizoaffective DisorderBipolar Type BMI: Past Psych Hx: 1 prior admission Medical Hx: None Relevant Medication Hx: Gender: Female Other: Allergies: No Known Allergies Vital Signs: BP: 104/72 Pulse: 87 Temp: 98 RR: 18 o2 Sat: 98 Family Psych Hx: None Known Presenting Problem: Patient came in presenting with aggressive behavior and delusions. ( Patient was aggressive towards her boyfriend who was holding their 1 year old child showing no care for safety of others) Relevant Labs: HCG serum Rationales (cite): Results: Positive for Pregnancy Current Medication (including PRN use): Haloperidol (5mg) – at bedtime Prenatal vitamin (1 tablet) – Morning Melatonin Assessment (Assessment, Prioritized Problem, Goals, Interventions and Evaluation must be done for each identified Problem) Subjective Data: Objective Data: – – Priority Problem #1 Risk For Self/Other Goal/s 1. 2. Interventions/Rationales/Citation (at least three) 1. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 2. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 3. Intervention: Rational: Citation(in text cite as well as add reference in apa format): Evaluation 2 | Page Assessment (Assessment, Prioritized Problem, Goals, Interventions and Evaluation must be done for each identified Problem) Subjective Data: Objective Data: – – Priority Problem #2 Goal/s 1. 2. Interventions/Rationales/Citation 1. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 2. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 3. Intervention: Rational: Citation(in text cite as well as add reference in apa format): Evaluation 3 | Page Assessment (Assessment, Prioritized Problem, Goals, Interventions and Evaluation must be done for each identified Problem) Subjective Data: Objective Data: – – Priority Problem #3 Adhering to medication Regimen Goal/s 1. 2. Interventions/Rationales/Citation (at least three) 1. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 2. Intervention: Rational: Citation(in text cite as well as add reference in apa format): 3. Intervention: Rational: Citation(in text cite as well as add reference in apa format): Evaluation 4 | Page
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