Nursing Care Plan
CONCEPT MAP
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Order Paper NowHistory of Present Illness (HPI)
Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (3)
Pathophysiology of Medical History (3)
Surgical History
Social History
Patient Info (1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
Allergies:
Erickson’s Developmental Stage Related to pt. & Cite References (1)
Chief Complaint
Admitting Diagnosis
Concept Map
Student Name:
Instructor: Blackard
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
RT
Freq.
MOA
RN Considerations
Onset/Peak/Duration
(Insulin)
Medical Management/ Orders/ Medications & Allergies
Name
Dose
RT
Freq.
MOA
RN Considerations
Onset/Peak/Duration
(Insulin)
Medical Management/ Orders/ Medications & Allergies
Name
Dose
RT
Freq.
MOA
RN Considerations
Onset/Peak/Duration
(Insulin)
Medical Management/ Orders/ Medications & Allergies
Name
Dose
RT
Freq.
MOA
RN Considerations
Onset/Peak/Duration
(Insulin)
Cultural considerations, ethnicity, occupation, religion, family support, insurance.
Diagnostic Test/ Lab Results with dates and Normal Ranges
Test
Norms
Date
Current Value
WBC
4.40-11
Hgb
14.0- 16.0
Hct
36-42
Platelets
150-450
Na+
135-145
K+
3.5-5.0
Creatinine
0.6-1.3
Blood Glucose
76-106
BUN
8.0-30.0
Troponins
0.0-0.4
BNP
>125pg/mL
ALT
7 to 56
Ca+
8.5 – 10.5
Albumin
3.5 – 5.5
AST
10- 40
Blood cultures
Cholesterol
100 to 129
Triglycerides
HDL
40 – 59
LDL
100 -129
Neurological
Vital Signs (4)
Cardiovascular
Respiratory
Rest/Exercise
Nutrition/Hydration
Misc. (Ht/Wt)
Integumentary
GI
GU
Psychosocial (14)
Endocrine
Patient Education (In Pt.) & Discharge Planning (home needs )
Patient Education while in patient:
Discharge Planning/Education:
Priority nursing diagnosis #1
Priority nursing diagnosis #1
Outcome/Goal #1
Outcome/Goal #2
Interventions #1
Assessment/ Evaluation #1
Interventions # 2
Assessment/ Evaluation #2
PC Outcomes/Goal
.
PC Interventions
Potential Complications/ at risk for
PC Evaluation Plan
References: