NSG 110 Case Study for Concept Map #1

Mr. RC. Is an 81-year old who is admitted from the hospital to your long- term care facility. He was in the hospital for pneumonia. His wife of 55 years has decided she is unable to care for him at home. Mrs. RC states “He has gotten too weak for me to care for him. I’m afraid he will fall and hurt himself. I’m not well myself and I’m too weak to continue to bathe, dress and feed him. He is so forgetful. I’m afraid he’s going to burn the house down. I hope I’m doing the best thing for him.”

You complete your assessment and these are your findings. Oriented to self and wife only. Cannot tell you the day, time or state he lives in. VS 97.6o F, heart rate is 72 and regular, respirations are 20, blood pressure is 146/84, SPO2 is 96% on room air. Can follow only very simple commands. He can walk holding on to the hand rails in the hallway, but gait is unsteady. 

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 Systems Subjective Data Objective Data
Neurologic
HEENT (Head, Eyes, Ears, Nose, Throat)
Integument
Musculoskeletal
Cardiovascular
Respiratory
GI
GU
Emotional/Social/Spiritual
Reproductive

Step 2: Place the subjective and objective data under the appropriate Gordon’s Functional 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