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Concept Map
Student Name:
Instructor:
Date of Care:
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT
TO THE HOSPITAL? (USE SEPARATE SHEET WHEN NEEDED)
Patient Information
(1)
Patient Initials:
Age & Gender:
Height/Weight:
Medical History:
PAST DIAGNOSED MEDICAL PROBLEMS
Code Status:
Parents or Guardian:
Surgical History:
PAST DIAGNOSED SURGICAL PROBLEMS
Chief Complaint
Admitting Diagnosis & Admission Date
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1)
(14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health (SDOH)
❋Economic Stability
❋ Education -school
❋Social and Community Context
❋ Health and Health Care
❋ Neighborhood and Built Environment
Parents-Who takes care of the child at home?
Siblings
Extended Family
(VM/GP/KL-V5)
(based on objective assessment)
Erickson’s Developmental Stage Related to pt. & Cite References (1)
*List and Discuss specific stage with real examples (based on
objective assessment)
Concept Map
Student Name:
Instructor:
Date of Care:
Medical Management and Collaborative Plan
(from MD, PT, OT notes)
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal
Ranges
Admission
Lab Values
Current
Lab Values
Explain Abnormal
Labs R/T Your Pt
Patient Education (In Pt.) for Transfer/ Discharge Planning
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): Patient’s age, Parents Present, LANGUAGE,
EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or
DISCHARGE
INCLUDE:
Appro.
Diagnostic Tests/
ProceduresDATEs and
RESULTS
(VM/GP/KL-V5)
EQUIPMENT
MEDS
TREATMENT
REFERRALS NEEDED-
Medications & Allergies (2)
Medication Name
Dose –
Show math with mg/kg for your
patient’s weight
(VM/GP/KL-V5)
Route
Freq.
Indications (PRN meds must
include MD ordered
Indication)
Mechanism of
Action
Side Effects/
Adverse
Reactions
Nursing
Considerations
Concept Map
ASSESSMENT/
REVIEW OF SYTEMS
Student Name:
Instructor:
Date of Care:
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
INSPECTION
HEAD
FOCUSED
Musculoskeletal
(8)
GI
Hydration/Nutrition (9)
GU (10)
TO
ASSESSMENT
PALPATION
ASCULTATION
Respiratory (7)
Rest/ Exercise (11)
TOE
-OR-
Endocrine (13)
Psychosocial (14)
Integumentary (12)
ASCULTATION
PALPATION
(VM/GP/KL-V5)
ASSESSEMENT
Misc.
PLAN OF CARE
Concept Map
Student Name:
Instructor:
Date of Care:
Priority Nursing Diagnosis #2
Priority Nursing Diagnosis #1
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB →
assessment findings/ diagnostics___________
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB →
assessment findings/ diagnostics
Intervention #1
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower
hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive
spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests,
procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update
MD/PA/NP
(Enough to accomplish the Goal)
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED
Evaluation #1
Evaluation #2
GOAL MET
GOAL PARTIALLY MET
GOAL MET
GOAL PARTIALLY MET
(EXPLANATION OF PARTIAL)
(EXPLANATION OF PARTIAL)
GOAL NOT MET
GOAL NOT MET
(EXPLANATION OF WHY-NOT
MET)
(EXPLANATION OF WHY-NOT
MET)
At Risk Interventions
At Risk Dx.PT AT RISK FOR…
Nsg Dx R/T _______
At Risk Outcomes/
Goal
S-STATES, PRESENTS, WILL BE
ABLE…
M-AMOUNT, NO. OF TIMES…
A-TTAINABLE
R-EALISTIC
T-w/IN THE HOUR(S), BY END OF
SHIFT, BY DISCHARGE DAY
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition,
elevate/lower hob/extrem. cool measures
(heat/ice),
ambulate, imagery/distraction, incentive
spirometer, tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests,
procedures, room/unit/phone/visitors
COLLABORATE: w/MDT & update
MD/PA/NP
(Enough to accomplish the Goal)
At Risk Evaluation Plan
(TO PREVENT BECOMING ACTUAL PROBLEM)
ASSESS: system, site, pt problem
MONITOR: labs, dx, loc
NON PHARM: reposition, elevate/lower
hob/extrem. cool measures (heat/ice),
ambulate, imagery/distraction, incentive spirometer,
tcdb.
ADMIN MEDS: r/t to problem
PT EDU: meds, treatments, tests, procedures,
room/unit/phone/visitors
(VM/GP/KL-V5)
Interventions # 2
COLLABORATE: w/MDT & update MD/PA/NP
GOAL MET
GOAL PARTIALLY MET
(EXPLANATION OF PARTIAL)
GOAL NOT MET
(EXPLANATION OF WHY-NOT
MET and possible revision of plan)

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