Name: ____________________________

_____________________ PAGE 1

Date: _____________

Client Initials: ________

Instructor:

Clinical Concept Map
Primary Medical Diagnosis

Pathophysiology
(reference)

History of Present
Illness

Medications that Impact
Medical Diagnosis
(briefly identify how
they impact the medical
diagnosis)

Health History

PHYSICAL ASSESSMENT PAGE 2 Neuro:________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ____ Respiratory:__________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _____ Cardiovascular:______________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _____ Gastrointestinal::____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ______ .

PAGE 3 Genitourinary:_______________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ______ Musculoskeletal:_____________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _____ Endocrine:___________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _____ Integumentary:______________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ______ .

phenylalanine hydroxylase. . Bilirubin screen 1.5-2 mg/dL Used to detect a hepatic enzyme deficiency. that prevents the conversion of phenylalanine to tyrosine in the infant.0-12.Immune System________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ ___ PAGE 4 Lab Tests Norm s Action & Significance to Diagnosis (relate to disease process & meds – be specific) PKU metabolic screen 0. Jaundice occurs if the newborn’s liver is immature and does not have enough conjugating enzymes.0 mg/dL Used to indicate liver function. Part of the evaluation of newborns with jaundice.

relate to disease process & labs – be specific ) .Medication Class: Trade/Gener Pharm/ ic Therapeuti c Dosage & Frequen cy Rout e Why Prescribed for THIS client (mechanism of action.

Medications PAGE 5 .

IV Medications PAGE 6 .

PRN Medications Medication Class: Trade/Gener Phar/ ic Therapeuti c Dosage Rout & e Frequen cy Why Prescribed for THIS client (mechanism of action. relate to disease process & labs – be specific ) .

PAGE 7 Medication Class: Trade/Gener Phar/ ic Therapeuti c Dosage & Frequen cy Rout e Why Prescribed for THIS client (mechanism of action. relate to disease process & labs – be specific) .

PAGE 8 Medical Diagnosis Priority Nursing Diagnosis Related to As evidenced by #2 Nursing Diagnosis #3 Nursing Diagnosis #4 Nursing Diagnosis #5 Nursing Diagnosis Related to Related to Related to Related to As evidenced by As evidenced by As evidenced by As evidenced by .

PAGE 9 Priority Nursing Diagnosis ______________________ ______________________ ______________________ ______________________ ______________________ ________________ Long Term Goal ________________________ ________________________ ________________________ _________________ Supporting Assessment Data _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ ________________ Short Term Goal _________________________ _________________________ _____________________ _________________________ .

Priority Nursing Interventions Page 10 #1 Intervention #2 Intervention #6 Intervention Priority Nursing Diagnosis #5 Intervention #3 Intervention #4 Intervention .

Additional Nursing Interventions Page 11 # # Intervention # Intervention # Intervention Intervention Priority Nursing Diagnosis # Intervention # Intervention .

#: Evaluation: PAGE 12 . #: Evaluation: #2 Intervention: Rationale with reference & pg.Priority Nursing Diagnosis #1 Intervention: Rationale with reference & pg. #: Evaluation: #3 Intervention: Rationale with reference & pg.

#: Evaluation: #6 Intervention: Rationale with reference & pg. #: Evaluation: #5 Intervention: Rationale with reference & pg. #: Evaluation: PAGE 13 .Priority Nursing Diagnosis #4 Intervention: Rationale with reference & pg.

PAGE 14 References .

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