Concept Map And Case Study 2
Concept map template
Nursing 110
Name:
Class:
Due Date:
Patient’s Initials:
Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box.
| Body Systems | Subjective Data | Objective Data |
| Neurologic | ||
| HEENT (Head, Eyes, Ears, Nose, Throat) | ||
| Integument | ||
| Musculoskeletal | ||
| Cardiovascular | ||
| Respiratory | ||
| GI | ||
| GU | ||
| Emotional/Social/Spiritual | ||
| Reproductive |
*
Step 2: Group the subjective and objective data that belong together in the same data cluster. Identify the correct Gordon’s Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed.
Clustered Data (all relevant)
Relevant Gordon Pattern: Health Perception/Health Management
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Sleep/Rest
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Sexuality/Reproductive
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Value/Belief
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Cognitive/Perception
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Elimination
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Nutrition/Metabolic
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Activity/Exercise
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Coping/Stress
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Role/Relationship
Definition:
Patient Name:
Age:
Gender:
Chief Complaint:
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
Patient Name:
Age:
Gender:
Situation:
Priority Nursing Diagnostic Statement:
Diagnostic Label
Related to
Evidence
Goal:
2-3 SMART outcomes:
1.
2.
3,
In your own words, based on the data cues, what is the most important (priority) problem?
List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3):
1.
Step 3: Type in the Data Clusters. Identify the Gordon’s Pattern and functionality; Analyze the data cluster to determine the problem. Identify the appropriate Nursing Diagnostic Label (nursing diagnosis). Complete the remaining sections. Include arrows showing how each data cluster/problem influences others on the care map. . Add, Expand, or Rearrange the boxes as needed.
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
References