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Student Name:: Clinical Week #: Clinical Instructor

This document contains a nursing concept map (NCM) for a clinical patient. The NCM includes sections for the patient's medical diagnosis, pathophysiology, health history, current orders and medications with rationales, lab results, details of any recent surgical procedures, medication rationales, presenting symptoms, diagnostic tests, nursing diagnoses, and care plan interventions with expected outcomes and evaluations. The NCM is intended to comprehensively document the patient's case for a nursing student's clinical rotation.

Uploaded by

Susan Benson
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© Attribution Non-Commercial (BY-NC)
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112 views5 pages

Student Name:: Clinical Week #: Clinical Instructor

This document contains a nursing concept map (NCM) for a clinical patient. The NCM includes sections for the patient's medical diagnosis, pathophysiology, health history, current orders and medications with rationales, lab results, details of any recent surgical procedures, medication rationales, presenting symptoms, diagnostic tests, nursing diagnoses, and care plan interventions with expected outcomes and evaluations. The NCM is intended to comprehensively document the patient's case for a nursing student's clinical rotation.

Uploaded by

Susan Benson
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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98999743.

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BELLEVUE COMMUNITY COLLEGE Associate Degree Nursing Program Bellevue, Washington

Student Name: Clinical Week #: Clinical Instructor:

N101 NURSING CONCEPT MAP (NCM)


Instructor Comments:

Client Initials: Age: Date of Admission: Hospital day # Date: Medical Diagnosis: Surgical Diagnosis: Current Vital Signs: 1) BP _______ P _______ RR ________ T _______ 2) BP _______ P _______ RR ________ T _______

PATHOPHYSIOLOGY: Briefly describe the following utilizing one of your clients medical diagnoses Pathophysiology

Etiology and/or risk factors of the pathophysiology:

S/S of the pathophysiology:

Effect of this pathophysiology on the client:

OTHER SIGNIFICANT HEALTH HISTORY

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Currently relevant orders, prescribed medications and therapies within past 24 hours (PLEASE NUMBER) 1. Diet: 2. Vital signs 3. Activity: 4. Wound care: 5. IV fluid: 6. Diagnostic procedures/ labs:

WRITTEN rationales for each order, prescribed medication and therapies (PLEASE NUMBER TO CORRESPOND TO LEFT COLUMN) 1. Rationale: 2. Rationale: 3. Rationale: 4. Rationale: 5. Rationale: 6. Rationale

7. Therapies

7. Rationale:

LAB RESULTS:

BRIEF DESCRIPTION OF SURGICAL OR INTERVENTIONAL PROCEDURE Name of procedure: ____________________ Description of procedure: Surgery or Intervention date ________ POD # _______

Risks and benefits of procedure: Potential complications: Nursing considerations:

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RATIONALES FOR PRESCRIBED MEDICATIONS: Routine meds (scheduled) and any PRN given within past 24 hours (add pages as needed) DIRECTIONS: add pages as needed to include all you clients current prescribed meds and PRNs MEDICATION (generic and Trade name, drug classification Dose, route, frequency MECHANISM OF ACTION EFFECT ON CLIENT WHY CLIENT IS TAKING THIS MED NURSING CONCIDERATIONS

Presenting Symptoms

Lab and Diagnostic Tests

Nursing Diagnosis

Nursing Diagnosis

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Data

Reason for Seeking Health Care (Medical Diagnosis) Data Expected Outcome

Expected Outcome

Pre-Existing Medical Conditions

Risk Factors

Interventions

Data Nursing Diagnosis Nursing Diagnosis

Data

Interventions

Evaluation

Expected Outcome

Expected Outcome

Evaluation

Interventions

Interventions

Evaluation

Evaluation

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