CONCEPT

MAP
NUR222
 CONCEPT MAP
I. Demographic Data
II. ABCDE Assessment
III. Focused Assessment
IV. Subjective and objective data
V. Laboratory investigations
VI. Prioritized nursing diagnosis
 I. Demographic Data

• Patient initials • Occupation

• Gender • Level of Education
• Age • Admission diagnosis
• Religion • Place of birth
• Date of admission • PMH
• Chief complain • PSH
 II. ABCDE Assessment
1. Airway :
Spontaneous via: Room Air (RA) Face Mask Cannula
Artificial Airway : Endotracheal Tube (ETT) ,
Tracheostomy
 2. Breathing

Respiratory Rate: Breath/min

Respiratory Rhythm: Regular, Irregular
Respiratory Depth :Normal, Shallow, Deep
Respiratory Effort: Accessory muscles used? (yes/no)
Symmetrical chest movement? (yes/no)
Abdominal breathing? (yes/no)
Cough present? (yes/no)
Cough productive? If applicable (yes/no)
 3.Circulation
Apical pulse
Rate: ______beat/min
Rhythm :Regular, Irregular
Abnormal Heart sounds : Murmur, Thrill
Capillary refill time: < 2 secs, >2 secs
 4. Disability & 5.Exposure
Disability:

• Level of consciousness

• ADL: tolerance or Mobility Status

Exposure:

• Body temperature

• Bleeding
 III. Focused Assessment of the Relevant System

I: Inspection

P: Palpation

P: Percussion

A: Auscultation

For the relevant system according to history taking and ABCDE assessment
 IV. Subjective and Objective Data

According to client’s complain, history taking and ABCDE

assessment
 V. Laboratory Investigations

According to the client’s complain, history taking and ABCDE

assessment
For example:
 Blood glucose level
 Complete Blood Count
 Coagulation profile
 VI. Prioritized Nursing Diagnosis
According to the client’s
• History taking,
• ABCDE assessment,
• Focused Assessment of the Relevant System
• Subjective and Objective Data

Formulate the nursing diagnosis using NANDA taxonomy.

Any Questions?

Thanks