Concept map template
Nursing 110
Name:
Class:
Due Date:
Patients 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 Gordons 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 Gordons 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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