CONCEPT MAP PNEUMONIA

Patient Information

(1)

Patient Initials:

 

Age & Gender:

 

Height/Weight:

 

Code Status:

 

Parents or Guardian:

 

 

 

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL? (USE SEPARATE SHEET WHEN NEEDED)

 

 

 

 

 

 

Medical History:

PAST DIAGNOSED MEDICAL PROBLEMS

 

 

 

 

 

Surgical History:

PAST DIAGNOSED SURGICAL PROBLEMS

 

 

 

 

Social History:

SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE

 

Chief Complaint

 

 

 

 

Admitting Diagnosis & Admission Date

 

 

 

Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage with real examples (based on objective assessment)

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)

❋Economic Stability

❋ Education -school

❋Social and Community Context

❋ Health and Health Care

❋ Neighborhood and Built Environment

Parents-Who takes care of the child at home?

Siblings

Extended Family

 

 

(based on objective assessment)

 

 

 

Concept Map

Student Name:

Instructor:

Date of Care:

 

 

 

 

ANTICIPATED TRANSFER/ DISCHARGE PLANNING:

DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE

 

EQUIPMENT

MEDS

TREATMENT

 

REFERRALS NEEDED-

 

Medical Management and Collaborative Plan

(from MD, PT, OT notes)

 

Patient Education (In Pt.) for Transfer/ Discharge Planning

 

ASSESS LEARNING STYLE:

LEARNING PREFERENCE: WRITTEN, VIDEO, etc.

 

LEARNING BARRIER(S): Patient’s age, Parents Present, LANGUAGE, EDUCATION LEVEL

ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.

 

 

 

 

 

 

 

 

Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)

 

 

Lab Tests

Normal Ranges

Admission Lab Values

 

Current Lab Values

Explain Abnormal Labs R/T Your Pt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCLUDE: Appro. Diagnostic Tests/ Procedures- DATEs and RESULTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concept Map

Student Name:

Instructor:

Date of Care:

 

 

 

Medications & Allergies (2)

 

Medication Name

Dose –

Show math with mg/kg for your patient’s weight

Route

Freq.

Indications (PRN meds must include MD ordered Indication)

Mechanism of Action

Side Effects/

Adverse Reactions

Nursing

Considerations

RN Considerations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory (7)

 

 

 

 

Cardiovascular (6)

 

 

 

FOCUSED

 

Vital Signs (4)

 

 

 

INSPECTION

Neurological (5)

 

 

 

HEAD

 

 

ASSESSMENT/

REVIEW OF SYTEMS

 

Concept Map

 

Student Name:

Instructor:

Date of Care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Musculoskeletal

(8)

 

 

 

PALPATION

ASCULTATION

 

 

 

-OR-

 

 

 

 

GI

Hydration/Nutrition (9)

 

 

TO

 

 

TOE

GU (10)

 

 

 

ASSESSMENT

 

Rest/ Exercise (11)

 

 

 

 

 

 

 

 

 

 

Misc.

 

Psychosocial (14)

 

 

 

Endocrine (13)

 

 

ASSESSEMENT

 

 

 

Integumentary (12)

 

 

 

ASCULTATION

PALPATION

 

 

 

Priority Nursing Diagnosis #1

APPROPRIATE NSG DX

WRITTEN CORRECTLY

i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics

 

Priority Nursing Diagnosis #2

APPROPRIATE NSG DX

WRITTEN CORRECTLY

i.e. Nsg. DX. R/T _________ AEB assessment findings/ diagnostics___________

 

Concept Map

 

Student Name:

Instructor:

Date of Care:

 

 

 

 

PLAN OF CARE

 

 

 

 

 

Evaluation #1

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET)

 

Intervention #1

 

ASSESS: system, site, pt problem

MONITOR: labs, dx, loc

NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),

ambulate, imagery/distraction, incentive spirometer, tcdb.

ADMIN MEDS: r/t to problem

PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors

COLLABORATE: w/MDT & update MD/PA/NP

 

 

(Enough to accomplish the Goal)

 

 

 

 

At Risk Dx.-

 

PT AT RISK FOR…

Nsg Dx R/T _______

 

 

 

 

Outcome/Goal #1

S-PECIFIC

M-EASURABLE

A-TTAINABLE

R-EALISTIC

T-IMED

Outcome/Goal #1

S-PECIFIC

M-EASURABLE

A-TTAINABLE

R-EALISTIC

T-IMED

At Risk Interventions

(TO PREVENT BECOMING ACTUAL PROBLEM)

ASSESS: system, site, pt problem

MONITOR: labs, dx, loc

NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),

ambulate, imagery/distraction, incentive spirometer, tcdb.

ADMIN MEDS: r/t to problem

PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors

COLLABORATE: w/MDT & update MD/PA/NP

 

At Risk Outcomes/

Goal

S-STATES, PRESENTS, WILL BE ABLE…

M-AMOUNT, NO. OF TIMES…

A-TTAINABLE

R-EALISTIC

T-w/IN THE HOUR(S), BY END OF SHIFT, BY DISCHARGE DAY

Evaluation #2

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET)

 

 

 

 

At Risk Evaluation Plan

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET and possible revision of plan)

 

 

 

 

Interventions # 2

 

ASSESS: system, site, pt problem

MONITOR: labs, dx, loc

NON PHARM: reposition, elevate/lower hob/extrem. cool measures (heat/ice),

ambulate, imagery/distraction, incentive spirometer, tcdb.

ADMIN MEDS: r/t to problem

PT EDU: meds, treatments, tests, procedures, room/unit/phone/visitors

COLLABORATE: w/MDT & update MD/PA/NP

 

(Enough to accomplish the Goal)

 

 

 

 

 

 

 

 

(VM/GP/KL-V5)