Create an imaginary patient in the Medical Surgical floor and fill in all of the regarding the patients current condition. I have attached below the word document which should be used. Do not delete any of the information currently on there. Attach a page with 3 APA formatted references.NursingConceptMap.docx Concept Map (TEMPLATE) Student Name: Instructor: DATE Care Provided and UNIT: Patient Information (1) Patient Initials: Age & Gender:Height/Weight:Code Status: Living Will/ DPOA: 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- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED) Medical History: (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED MEDICAL PROBLEMS Surgical History: (SEE RUBRIC REQUIREMENTS) 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 (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 ( MAY DELETE THESE ?TIPS? TO USE SPACE) ? Education ?Social and Community Context ? Health and Health Care ? Neighborhood and Built Environment Concept Map (TEMPLATE) Student Name: Instructor: DATE Care Provided and UNIT: 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: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS (Can add See attached Word Doc) ANTICIPATED TRANSFER/ DISCHARGE PLANNING: DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGEEQUIPMENT ( MAY DELETE THESE ?TIPS? TO USE SPACE) MEDS TREATMENT REFERRALS NEEDED Medical Management and Collaborative Plan (from MD, PT, OT notes?.etc.) *Consider past 24 ? 48 hours Patient Education (In Pt.) for Transfer/ Discharge Planning ASSESS LEARNING STYLE: LEARNING PREFERENCE: WRITTEN, VIDEO, etc. LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc. Medications & Allergies (2) Medication Name Dose Route Freq. Indications (PRN meds must include MD ordered Indication) Mechanism of Action Side Effects/ Adverse Reactions Nursing Considerations RN Considerations Concept Map (TEMPLATE) Student Name: Instructor: DATE Care Provided and UNIT: Respiratory (7) Cardiovascular (6) Vital Signs (4) Neurological (5) ASSESSMENT/ REVIEW OF SYTEMS Musculoskeletal (8) GI Hydration/Nutrition (9) GU (10) Rest/ Exercise (11) Integumentary (12) Misc. Psychosocial (14) Endocrine (13) Concept Map (TEMPLATE) Student Name: Instructor: DATE of Care Provided and UNIT: Priority Nursing Diagnosis #1 Priority Nursing Diagnosis #2 PLAN OF CARE Evaluation #1 Intervention #1 At Risk Dx.- Outcome/Goal #1 Outcome/Goal #1 At Risk Interventions At Risk Outcomes/ Goal Evaluation #2 At Risk Evaluation Plan Interventions # 2 (VM/GP/KL-V5)
