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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________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
___

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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 newborn’s 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
PRN Medications

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
PAGE 7

Medication Class: Dosage Rout Why Prescribed for THIS client


Trade/Gener Phar/ & e (mechanism of action, relate to
ic Therapeuti Frequen disease process & labs – be specific)
c cy
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
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Priority Nursing
Diagnosis
______________________
Supporting
______________________
Assessment Data
______________________
______________________ _______________________
______________________ _______________________
________________ _______________________
_______________________
_______________________
_______________________
________________
Long Term Goal
________________________
________________________ Short Term Goal
________________________
_________________ _________________________
_________________________
_____________________
_________________________
Priority Nursing Interventions
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#1 Intervention

#2 Intervention
#6 Intervention

Priority Nursing
Diagnosis

#5 Intervention #3 Intervention

#4 Intervention
Additional Nursing Interventions
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# Intervention

# Intervention
# Intervention

Priority Nursing
Diagnosis

# Intervention # Intervention

# Intervention
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Priority Nursing Diagnosis

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

Evaluation:

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

Evaluation:

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

Evaluation:
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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

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