concept map

Patient Information

(1)

Name:

Age:

Gender:

Code Status:

DPOA:

Living Will:

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns, to include the following Social Determinants of Health

❋Economic Stability ❋ Education

❋Social and Community Context ❋ Health and Health Care ❋ Neighborhood and Built Environment

 

 

 

 

 

 

Chief Complaint

 

 

 

 

Admitting Diagnosis

 

Medical Management/ Orders/ Medications & Allergies (2)

 

 

 

 

Erickson’s Developmental Stage Related to pt. & Cite References (1)

 

 

Patient Education (In Pt.) & Discharge Planning (home needs)

 

 

 

 

 

 

 

 

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

 

 

 

 

Medical History

 

 

 

 

Surgical History

 

 

 

 

Social History

 

Diagnostic Test/ Lab Results with dates and Normal Ranges (3)

 

 

 

Concept Map

Student Name:

Instructor:

 

 

PC Outcomes/Goal

 

 

Priority nursing diagnosis #2

 

 

Respiratory (7)

 

Vital Signs (4)

 

Integumentary (12)

 

 

Interventions # 2

 

Assessment/ Evaluation #1

 

Assessment/ Evaluation #2

 

 

PC Evaluation Plan

 

Potential Complications/ at risk for

 

PC Interventions

 

Psychosocial (14)

 

Cardiovascular (6)

 

 

Endocrine (13)

 

Misc. (Ht/Wt)

 

GU (10)

 

GI (9)

 

Nutrition/Hydration

(8)

 

Rest/ Exercise (11)

 

Neurological (5)

 

Outcome/Goal #1

 

Priority nursing diagnosis #1

 

Outcome/Goal #2

 

Interventions #1