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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%.

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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

Individual Care Map Evaluation Tool – NSG110

Name: _______________________ Date: ___________ Patient’s initials: _______________

Concept
(Follow instructions provided and on Moodle)
The student will:Maxi-mum Points/
Prepare: Written Analysis and Concept MapStudent pointsUnsatisfactory  SatisfactoryExceeds expectationsComments:
Identify and Organize the Assessment data from patient chart/case study. (Organized into subjective/objective data and by body system)Data disorganized and/or ≤ 60% included. (5pts.)Data not organization into subjective and objective data or by body system. ≤ 80% of data included (10pts.)Data organized into subjective and objective data or data organized by body system. 90-100% of data included (12pts.)Data organized into subjective and objective data and by body system. ≤80% of data included. (16 pts.)Data organized into subjective and objective data and by body system. 90-100% of data included. (20 pts) 
Demonstrate appropriate use of Gordon’s Functional Patterns by organizing data into meaningful data clusters. Functional or dysfunctional patterns correctly labeled. Each Gordon’s pattern is defined and has a citationData analysis is unorganized without relationship to Gordon’s patterns. < 67% of problems are identified or patterns not defined. Functional or dysfunctional patterns not labeled. (5pts)Data is not analyzed with relationship to Gordon’s patterns; OR does not clearly identify the human responses to the situation, Patterns not defined. > 80% Functional or dysfunctional patterns incorrectly labeled. (10pts)Data is not analyzed with relationship to Gordon’s patterns; does not clearly identify the human response with appropriate data; ≥ 67% of the problems are identified. Patterns defined missing citation. <80%Functional or dysfunctional patterns correctly labeled. (12pts)Data is analyzed with relationship to Gordon’s patterns; clearly identifies the human response to the health situation. ≤ 67% of the problems are identified. At least 80% of patterns are defined with citation. At least 80% Functional or dysfunctional patterns correctly labeled. (16pts)Data is analyzed with relationship to Gordon’s patterns; clearly identifies the priority human responses to the health situation. All patterns are defined with citation. Functional or dysfunctional patterns correctly labeled. (20pts) 
List at least 3 Nursing Diagnoses (NDx) based upon analysis of the data (must have at least 1 problem-oriented physiological NDx). All identified nursing diagnoses listed from highest priority to lowest priority.Does not list at least 3 nursing diagnosis and does not have at least 1 problem-oriented physiological NDx. Nursing diagnoses not prioritized. does not reflect understanding of the client problem (5pts.)At least 3 nursing diagnoses are listed and does not include at least 1 problem-oriented physiological NDx. Does not use NANDA approved nursing diagnoses. OR NDx components are complete in < 67% of the NDx. ≤ 67% of nursing diagnoses prioritized from highest to lowest priority. OR does not reflect understanding of the client problems. (8 pts)At least 3 nursing diagnoses are listed with at least 1 problem-oriented physiological NDx. NDx components are complete or correct in < 67% of the NDx. ≥ 67% of nursing diagnoses prioritized from most important to least important. Nursing diagnoses do not reflect understanding of the client problem. (10pts)Three (3) nursing diagnoses are listed with at least 1 problem-oriented physiological NDx. Components of the NDx are correct in ≥ 67% of NDx. ≥ 67% of nursing diagnoses prioritized from highest to lowest priority. Reflects understanding of the client problems. (12pts)More than 3 nursing diagnoses are listed with at least 1 problem-oriented physiological NDx. All components of the NDx (NANDA diagnosis, related to factors and evidence including all data for each problem) are included and correct for each NDx. All nursing diagnoses listed and prioritized from highest to lowest priority. Reflects understanding of the client problems. (15 pts) 
Correctly Planning care by writing a goal and outcomes for the priority nursing diagnosisGoal statement not included. Expected outcomes listed not in SMART format or do now show advancement toward goal achievement. Minimal effort. (5)Goal statement or ≤ 2 Expected outcomes are not patient-centered or missing one or more components. (8pts)Goal statement and ≤ 2 expected outcomes patient-centered; does not address the problem. (10pts)Writes one patient-centered goal addresses the problem and ≤ 2 expected outcomes in SMART format. (12pts)Writes one patient-centered goal and 3 or more expected outcomes in SMART format that show advancement toward goal achievement. . (15pts)
Use Care Map to Cluster and Analyze Data      
Format relevant Care Map:Relationships between concepts do not show critical thinking leading to identification of human response to the situation. Relationships between concepts with Care Map format poorly indicated. (5pts)Does not use care map template. Data clusters do not originate from the client. Or Data clusters do not demonstrate use of Gordon’s Patterns with the organization process and identification of Functional and Dysfunctional Patterns. Or Data clusters do not show critical thinking leading to identification of priority human response to the situation. Relationships between concepts poorly indicated. (10pts)Patient-centered care map developed. Uses care map template. All components of nursing process are identified and incorporated into the care map. Data cues organized data clusters which reveal Patterns of function or dysfunction. Relationships between concepts ambiguous. Does not show critical thinking leading to the identification of the priority NDx. (12pts)Patient-centered care map developed. Uses care map template. All components of nursing process are identified and incorporated into the care map. Data clusters which reveal Patterns of function or dysfunction. Relationships between concepts clearly indicated to include influences, results, and how each step of the nurse process affects the others. Does not show critical thinking leading to the identification of the priority NDx (16pts)Patient-centered care map developed. Uses care map template. All components of nursing process are identified and incorporated into the care map. Data clusters reveal Patterns of function or dysfunction (labeled). Relationships between concepts clearly indicated to include influences, results, and how each step of the nursing process affects the others. Demonstrates critical thinking leading to the identification of the priority NDx. (20pts) 
Communicate knowledge in a manner that is concise, comprehensible, and logically organized; apply APA style and formatting for citations and referencesDoes not communicate knowledge in a manner that is concise, comprehensible, and logically organized; does not apply APA style and formatting. (1pt)Communicates knowledge in a manner that is concise, comprehensible, and logically organized; applies APA style and formatting; assignment contains >=80% errors. (5pts)Empty spaceCommunicates knowledge in a manner that is concise, comprehensible, and logically organized; applies APA style and formatting for references; assignment contains <80% errors. (8 pts)Communicates knowledge in a manner that is concise, comprehensible, and logically organized; applies APA style and formatting for references; assignment contains no errors. (10 pts) 
Total Points Available/ Student Points Earned:100      

Satisfactory (80 points)

If satisfactory not met, correct named deficiencies and resubmit for further evaluation on ________ Initials____________

Faculty signature: ______________________ Student signature: __________________________

Rev October 2018 df; rev 5/2021 df

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