Copy of Template-Concept MapPatient Database

8/10/2019 Copy of Template-Concept MapPatient Database

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Student Name:

Date of CarePatient

InitialsAge Gender Admission Date

Living Will Yes No POA Yes No DNR Order Yes No

Laboratory Data

Normal

ValuesAdmission Yesterday Today

UA glucose, protein,etc.

CK MB

Troponin

Diagnostic Tests

Chest x-ray: EKG: Other Abnormal Reports:

Phosphorus

Bilirubin

Alkaline phosphatase

SGOT/SGPT

CK

Creatinine

ABGs (Ph, O2, CO2, HCO3)

Pre-albumin

Albumin

Calcium

BUN

APPT

Sodium

PotassiumChloride

Glucose

INR

Hemaglobin A1C

Growth and Development

(Piaget or Erikson's Stage)

Reason for hospitalization (face sheet):

Describe reason for hospitalization

Medical Dx:

Pathophysiology:All signs and symptoms

Surgical Procedures:Name of surgery (year) Describe

surgery

Chronic Illnesses (physician's H&P, nursing history):

ADVANCE DIRECTIVES

White blood cells (WBCs)

Test Reason for Abnormal Value

Red blood cells (RBCs)

Hemoglobin (Hgb)

Hematocrit (Hct)

Platelets

Prothrombin time (PT)


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Sputum or Blood culture: US: Other:


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OP D

1/2

M

E

OP D

1/2

M

E

OP D

1/2

M

E

OP D

1/2

M

E

O PD 1/2

M

ALLERGIES/PAINS

Dose

Administration Route

ClassificationAction

Reason the patient is receiving

PharmacokineticsOnset, Peak, Duration, 1/2 life, Metabolized, Eliminated

Contraindications

MAJOR adverse side effects

Nursing implications

Pt/Family teaching

Allergies:

Type of reaction(s)

When was the last time pain medication given?

Where is the pain? How much pain is the patient in on a scale 0-10?

Time Due

Brand Name

Generic Name

MEDICATIONS: List meds and times of administration, include OTCs and herbals


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List treatments: Rationale for treatments:

Dressing changes(type, location)

Ice

Foley (Fr, date of insertion)

NG (date of insertion )

Position changes q2h

Ted Hose

SCDs

IS q1h while awake

C&DB q1h while awake

Others

Type of diet: Restrictions: Appetite: B% L% D%

Yes No

What types of foods are included in this diet and what foods should be avoided?

Support Services: what do they do?

What does the consultant do for the patient?

Gag reflex intact

DIET/FLUIDS

What type of diet is this?

TREATMENTS

Fluid output

Tube feedings:

Type and rate

Problems: swallowing, chewing, dentures

Needs assistance with feeding

Nausea or vomiting

Over hydrated or dehydrated (evaluate total I&O)

Belching Other:

Circle those Problems That Apply

Prior 8 hours

Fluid intake (Oral and IV)

ELIMINATION

Last bowel movement: Foley/condom catheter:

Circle those Problems That Apply

INTRAVENOUS FLUIDS

Type and rate: IV dressing dry, no edema, redness of site Other:

Yes No

Type of activity orders Height (meters):

NEUROLOGICAL MENTAL STATUS

Ability to walk (gait) Weight (kilos):

Bowel constipation, diarrhea, flatus, incontinence, belching

Urinary hesitancy, frequency, burning incontinence, odor

Other

What is causing the problem in elimination?

ACTIVITY

LOC: alert and oriented to person, place, time, (A&Ox3)

confused,etc. GSC Score:________

Speech clear, appropriate, inappropriate

Pupils: PERRLA Sensory deficits for vision/hearing/taste/smell

MUSCULOSKELETAL STATUS


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Depth, rate;

rhythm

Use of

accessory

muscles

Cyanosis:

Oxygen

flow rate:

Edges

approximated

Yes No

Risk for

pressure

ulcer rating

NOTES:

Bones, joints, muscles (fractures, contractures, arthritis, spinal

curvatures, etc.)

Extremity (temperature, edema, (pitting vs. nonpitting)

& sensation

Ted hose/compression devices type: Cast, splint, collar, brace:

Motor: ROM x 4 extremities

Neck vein (distention):

Apical pulse:Sounds: S1 S2 Regular,

Irregular

Any chest pain:

Pulses (radial, pedal) to touch or Doppler:

RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM

Capillary refill


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Student:

Key Problem NIC 1

NIC 2 NIC

3

NIC 4

NIC 5

NIC 6

I don't know how this fits with the

problems

Key Problem ND

#3 NIC

NIC NICNIC NIC

NIC

Reason for Admission: Medical

Diagnosis/Surgical Procedure

Key Assessments:

Teaching

NIC #1 Assess readiness to learn

NIC

NIC

NIC

NIC

NIC

Medications 1

2

3 4

5

AAS RN Nursing Program Concept Map


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Complete your head to toe assessment. This information will be included in your patient profile.

Step 1-3. State what you believe are your patient's key problems. Center your patient's reason for bein

The key problems are also known as concepts. Next list the major problems around the center. Next l

treatments. Start to address the key problems and assign an appropriate Nursing Diagnosis. Once you

interventions and any complicaitons you will need to prevent. You must individualize your plan to your

Medications: it is important to recognized the general classifications to which each drug belongs. Anti

diagnosis related to an infection or potential for infection. Such as Impaired Urinary Elimination for UTI

antihypertensives are grouped with Decreased Cardiac Output, etc.

Laboratory and Diagnostic Tests: know which tests are ordered, their normal values, and the indication

A Concept Map contains the primary medical and nursing diagnoses, all the supporting data, and the re

maps organize data and thus improve the accuracy of nursing diagnoses.

There are 3 basic steps: 1. diagram propositions (key problems), 2. arrange data in hierachal order, and

the segments of the diagram.

Complete the Patient Database. For Concepts II you will need to look up most of the information to co

physical, psychosocial, social, and cultural components. It is important to note the chronic illnesses, y

signs and symptoms for your patient. This information will help you develop you nursing plan of care.

Include any and all teaching opportunities, material(s) taught, method of teaching (verbal, demonstratio

teaching (evaluation).


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Date:

Key Problem ND

#2 NIC

NIC NIC

NIC NIC

NIC

Key Problem ND

#4 NIC

NIC NICNIC NIC

NIC

Laboratory/Diagnostic test results


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g admitted (often the admitting diagnosis).

ok up your diagnoses, medications, and

have a Nursing Diagnosis list your nursing

patient.

iotics are grouped with the nursing

. Antidysrhythnmics and

s for any abnormal values for your patient.

lationships between diagnoses. Concept

3. make meaningful associations between

plete the database. The database has

ou will need to look them up, highlight the

n, etc.) and patient's response to the


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Problems, Goals, Outcomes

Problems, Goals, Outcomes

Evaluation: Summarize patient's progress towards outcome objective:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

_______________________________________________________________________________________________


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

Nursing Diagnosis #3 ____________________________________________________________________

Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________

Nursing Interventions Patient Responses


____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

______________________________________________________________________________________________


Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________


AAS RN Nursing Program Concept Map


Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________



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____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

_______________________________________________________________________________________________


Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________



____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

______________________________________________________________________________________________


Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________



____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

______________________________________________________________________________________________


Short Term Goal: ________________________________________________________________________

Long Term Goal:_________________________________________________________________________



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Concept Map Grading Rubric

Patient Initials: _________________ Student: ____________________

Class:_________________________ Date: ______________

Scoring Points Student

Initial focused assessment (patient profile/developmental stage) 40

Lab/Diagnostic tests: what tests are needed 5

Medications: dose, frequencym route, indications, side effects, nursing

implications10

Nursing Problems/Diagnoses: Identify (3 for novice/5 for advanced) cite

source 5

Interventions (3 short term/3 long term) with expected outcome for each,

cite source 30

Detailed evaluations for each short term/long term goal 10

Total Points 100

The student will complete the patient profile during clinical, review the patient lab/diagnostic tests and determine what if any are

abnormal and why, the student will list (5) medications to include all required elements, the nursing diagnoses will be determined

during clinical along with short term and long term goals, interventions, and patient's response to the interventions. Once the dat

is collected the student will develop the concept map. All documents will be turned in to the lead instructor 48 hours after their

clinical day.

Medical Careers Institute

Com


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