Name: ____________________________ Date: _____________ Client Initials: ________ Instructor:

_____________________ PAGE 1

Clinical Concept Map

Primary Medical Diagnosis

Pathophysiology History of Present Medications that Impact

(reference) Illness 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:______________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
___
Immune
System________________________________________________________________________________________________________

________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

PAGE 4

Lab Norm Action & Significance to Diagnosis (relate to

Tests s disease process & meds be specific)

PKU 0.5-2 Used to detect a hepatic enzyme deficiency, phenylalanine

metabolic mg/dL hydroxylase, that prevents the conversion of phenylalanine to
screen tyrosine in the infant.
Bilirubin 1.0-12.0 Used to indicate liver function. Part of the evaluation of newborns
screen mg/dL with jaundice. Jaundice occurs if the newborns liver is immature
and does not have enough conjugating enzymes.
 Medication Class: Dosage Rout Why Prescribed for THIS client
Trade/Gener Pharm/ & e (mechanism of action, relate to disease
ic Therapeuti Frequen process & labs be specific )
c cy
Medications
PAGE 5
 IV Medications
PAGE 6

Medication Class: Dosage Rout Why Prescribed for THIS client

Trade/Gener Phar/ & e (mechanism of action, relate to disease
ic Therapeuti Frequen process & labs be specific )
c cy
 PRN Medications
PAGE 7

Medication Class: Dosage Rout Why Prescribed for THIS client

Trade/Gener Phar/ & e (mechanism of action, relate to
ic Therapeuti Frequenc disease process & labs be specific)
c y
 PAGE 8
Medical Diagnosis

Priority #2 Nursing #3 Nursing #4 Nursing #5 Nursing

Nursing Diagnosis Diagnosis Diagnosis Diagnosis
Diagnosis

Related to Related to Related to Related to

Related to

As As As As
As evidenced evidenced evidenced evidenced
evidenced by by by by
by
 PAGE 9
Priority Nursing
Diagnosis
______________________
Supporting
______________________
Assessment Data
______________________
______________________ _______________________
______________________ _______________________
________________ _______________________
_______________________
_______________________
_______________________
________________
Long Term Goal
________________________
________________________ 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

Priority Nursing
Diagnosis

# Intervention # Intervention

# Intervention
 PAGE 12
Priority Nursing Diagnosis

#1 Intervention:
Rationale with reference & pg. #:

Evaluation:

#2 Intervention:
Rationale with reference & pg. #:

Evaluation:

#3 Intervention:
Rationale with reference & pg. #:

Evaluation:
 PAGE 13
Priority Nursing Diagnosis

#4 Intervention:
Rationale with reference & pg. #:

Evaluation:

#5 Intervention:
Rationale with reference & pg. #:

Evaluation:

#6 Intervention:
Rationale with reference & pg. #:

Evaluation:
 PAGE 14
References