Nursing Concept Map

Mr. Charles Lamont is a 45-year-old patient who is visiting his primary care physician for his an annual checkup. His wife is waiting for him in the lobby; she is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. Mr. Lamont works for a construction company as a heavy machine operator. He smokes 1½ packs of cigarettes per day. His wife has been encouraging Mr. Lamont to stop, but he has not showed any interest in quitting. Laura, the registered nurse, takes Mr. Lamont to an examination room. Laura asks him about his overall health and he tells her about a nagging cough and how he sometimes feels short of breath. He then denies any other health problems. Laura takes Mr. Lamont’s vital signs and gets the following results: blood pressure, 156/94 mm Hg; temperature, 99.8° F orally; apical pulse, 104 beats/min; respiration, 25 breaths/min and regular; and pulse oximetry, 95%.

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 SystemsSubjective DataObjective 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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