NSG 120 Straford University Week 8 Pneumonia Infection Concept Map I will like you to do a concept map with Pneumonia infection and always be wear of plagiarism Concept map template
Nsg 120
Assessment
Subjective Data:
60 year old male
Rates pain in L chest as a 6 on a scale from 1 to 10
objective data:
Patient seems anxious when talking about the
likelihood a cardiac condition
Body Systems:
Here you will put your head to toe
data.
Gordon Pattern:
Self Perception
Cluster data:
Use as many of
these as
appropriate. You
do not have to fill
them all.
Gordon Pattern:
Gordon Pattern:
Dysfunctional
Activity-Exercise
Nutritional-Metabolic
Cluster data:
inadequate diet,
loss of appetite
around painful
episodes
Dysfunctional
Cluster data:
Gordon Pattern:
Gordon Pattern:
Cluster data:
Cluster data:
Inability to complete daily
ADLS
Patient:
Priority Nsg Dx:
Impaired tissue perfusion related to cardiac condition as evidenced by chest
pain.
Evidence-based rationale for
interventions: ** you need rationales
with a source for each intervention
Pt has positive EKG therefore the
physician will order oxygen, pain
medications, and a cardiac
catheterization to rule out or rule in
myocardial infarction or MI ( need to
have a source to support your
rationale.)
Interventions: * you need 3 of these
Goal/Expected outcomes:
Pt pain will be below 6 out of 10 by the end of the end of the
shift today.
1. Physician will order an EKG
2. Administratino of pain medication and
oxygen.
3. Patient will be prepped for procedure.
Evaluation:
7.Patient stated that they are chest pain free
Nursing
120
8.Pt states her pain is still a 6 out of 10.
References
Doenges, M. E., & Moorhouse, M. F. (2013). Application of nursing process and nursing diagnosis: an
interactive text for diagnostic reasoning (6th ed.). Philadelphia: F.A. Davis.
Laskowski, M. E. (2015, August 22). 2 easy, accurate ways to measure your heart rate. Retrieved from
https://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/heart-rate/faq-20057979
Pollack, D. (2017 January 24). Nursing Diagnosis & Functional Health Patterns Cheat Sheet. Retrieved
from https://www.cheatography.com/davidpol/chea-sheets/nursing-diagnosis-and-functional-healthpatterns/
Individual Care Map Evaluation Tool
Name: _______________________ Date: ___________ Patient’s initials: _______________
Concept
(Follow instructions
provided and on Moodle)
The student will:
Maximum
Points/
Prepare: Written
Analysis (50 pts) and
Concept Map
Student
points
Selects relevant
objective and subjective
assessment data for the
client situation.
5
Organizes relevant
data into objective
and subjective
data.(2)
Demonstrate appropriate
use of Gordon’s
Functional Patterns by
organizing data into
meaningful data clusters
to determine priority
problem
5
Data cluster
complete the
support Gordon’s
patterns selected
(3)
Empty space
Data clusters
present, < 80% of
relevant data
uncluded,
appropriate
Gordon’s pattern
selected (2.5)
Empty space
Data clusters do
not support
Gordon’s pattern
selected. (1)
Plans appropriate care
for client:
• Goal statement
• Expected outcomes
10
Goal statement
reflects resolution
or reduction of
priority problem
identified. (2)
Empty space
Empty space
Empty space
Client goal does
not address the
nursing diagnosis
or Expected
outcomes do not
support goal
achievement or
are no written in
SMART format.
(0.5)
Comments:
Does not organize
data.(1)
20
3 or more nursing
interventions listed
address the cause
of the problem and
help the client
achieve the goal
use evidence
based practice,
individualized for
the patient, each
intervention has
rationale with APA
citation and
reference. (20)
≤ 3 nursing
interventions
listed address the
cause of the
problem and help
the client achieve
the goal, use
evidence based
practice, each
intervention has
rationale with
APA citation and
reference. (18)
≤ 3 Interventions
listed do not
address the cause
of the problem nor
help the client
achieve the goal,
use evidence
based practice, or
not relevant for
the patient, each
intervention has
rationale with APA
citation and
reference. (16)
Interventions(s)
do not address
the cause of the
problem nor assist
the client to
achieve the goal
with evidence
based practice, Or
rationale
inappropriate for
the selected
interventions,
each intervention
has with APA
citation and
reference (10)
Interventions
without rationale
or APA citation
and reference (0)
Format relevant Care
Map: Patient is
represented and data cues
organized into data
clusters which reveal
10
Relationships
between concepts
indicated as
cause/effect,
indications,
examples, leading
to conclusions, etc.
Indicates how each
step in the nursing
process affects the
others, and is
formatted logically.
(10)
Relationships
between
concepts
indicated as
cause/effect,
indications,
examples,
leading to
conclusions, etc.
Does not indicate
how each step in
the nursing
process affects
the others;
formatted
logically. (9)
Does not originate
from the client OR
Relationships
between concepts
indicated as
cause/effect,
indications,
examples, leading
to conclusions,
etc. Indicates how
each step in the
nursing process
affects the others,
and is formatted
logically. (7)
Data originates
from the client.
Two or more of
the following is
not present:
Relationships
between concepts
indicated as
cause/effect,
indications,
examples, leading
to conclusions,
etc. Or Indicates
how each step in
the nursing
process affects
the others, Or is
formatted
logically. (5)
Does not originate
from the client.
Relationships
between concepts
are illogical or do
not indicate
cause/effect.
Steps in nursing
process not
included. (2)
Total Points Available/
Student Points Earned:
50
Plans appropriate care
for client:
• Nursing interventions
• Clearly support
interventions with one
individualized EBP
rationale per
intervention and write a
citation for each
intervention.
Use Care Map to plan
client care
Faculty signature: ______________________Student signature: __________________________
Concept map template
Nsg 120
Assessment
Subjective /objective
data
Gordon Pattern
and cluster data
Gordon Pattern
and cluster data
Gordon Pattern
and cluster data
Gordon Pattern
and cluster data
Gordon Pattern
and cluster data
Body Systems
Patient
Evidence-based rationale
for interventions
Interventions
Priority Nsg D
Goal/Expected outcomes
Evaluation
Nursing
120
Include on the care map all parts of the nursing process using the template provided:
1. Please list all data cluster sets and which Gordon’s pattern are represented by each data cluster in the box on the template.
Which Gordon’s patterns are Functional or Dysfunctional?
2. List the identified nursing diagnoses correctly written in priority order from highest to lowest priority.
NDx: Problem related to ________ Evidenced by ____________ (include all of the evidence from the cluster): this problem is
the priority because…..next problem, etc.
3. Write a patient-centered goal statement to reduce or resolve the problem identified.
4. Write patient-centered expected outcomes in SMART format showing advancement toward the goal.
5. List all chosen nursing interventions and provide evidence based rationale for each intervention. Each interventions chosen
needs to help this patient to meet his or her goal? (Look at each intervention and explain.) All nursing interventions and evid
based rationales must have a citation.
6. What reassessment data would a nurse expect to assess if the client is meeting his or her goal? And Write at least one
reassessment data that would indicate the client is not meeting the goal? Put this in the evaluation box on the template.
7. Please be sure to include all references on your reference page.
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