Concept Map Tool - tool for clinicals PDF

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Summary

tool for clinicals...

Description

Nova Southeastern University Ron and Kathy Assaf College of Nursing NUR 3180: Data Collection/Concept Map Student’s Name: Date: Information based on physical assessment and retrieved from patient’s medical record: Primary RN Initials:

Patient’s Initials:

Admission Date:

Chief Complaint: What brought the patient into the hospital?

Admitting Dx:

Medical Hx:

Surgical Hx:

Psychosocial Hx

Marital status:

Religion:

Ethnicity:

Weight:

Activity level:

Pain:

O 2:

Allergies (medication and food): Patient Assessment: Neurologic:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Smoker:

Age:

Sex:

Alcohol use:

Illicit drug use:

Height:

Code Status:

Accu-checks:

Vital Signs:

Diet:

Integumentary:

Musculoskeletal:

List of things to follow-up from assessment and report:

Pathophysiology Primary Patient Disorder: Pathophysiology from Textbook:

Textbook or Reference Information Causes of Disorder: Risk Factors Associated with Disorder: Signs & Symptoms Subjective:

Objective:

Potential Complications:

Patient’s Presentation (Compare with the Textbook)

Trade (generic) Name for each Medication

List the Dose, Route, & Frequency

Therapeutic Classification of Medication

Describe the Purpose & Indication for each Medication

List the Major Side Effects

Medication Administration: What would be assessed prior to and after administering medication? Nursing actions related to monitoring effects of medication. What would be evaluated and how often related to effectiveness of medication?

Patient PRN Medications Generic & Trade Name for each Medication

List the Dose, Therapeutic Route, & Classification Frequency of Medication

Describe the List the Major Purpose and Side Effects Indication for Each Medication

Medication Administration: What would be assessed prior to and after administering medication? Nursing actions related to monitoring effects of medication. What would be evaluated and how often related to effectiveness of medication?

Intravenous Administration Name and Type of IV Fluids

Rate

Site/Insertion Date

Reason for IV Fluid?

IV Site Assessment

Admission and Most Current Significant Laboratory Data Date

Lab Study

Result

Normal Values

Significance of Abnormal Values

Diagnostic Tests Date

Test/Procedure

Results

Nursing Implications

CONCEPT MAP Nursing Diagnosis

Nursing Diagnosis

Subjective Data:

Subjective Data:

Objective Data:

Objective Data:

Reason for Seeking Health Care (Admitting Diagnosis)

Nursing Diagnosis

Nursing Diagnosis

Subjective Data: Subjective Data:

Objective Data: Objective Data:

PLAN OF CARE PRIORITY #1 Nursing Diagnosis: Intervention (s) The nurse will

Rationale

Expected Outcome: The patient will PRIORITY #2 Nursing Diagnosis: Intervention (s) The nurse will

Rationale

Expected Outcome: The patient will PRIORITY #3 Nursing Diagnosis: Intervention (s) The nurse will

Rationale

Expected Outcome: The patient will PRIORITY #4 Nursing Diagnosis: Intervention (s) The nurse will

Rationale

Expected Outcome: The patient will

Narrative Nurse’s Note: Day 1

Date/Time Nurse’s Note

Signature

Narrative Nurse’s Note: Day 2

Date/Time Nurse’s Note

Signature...