Attachments

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


 

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