concept map

Healthcare Facility

Age

Primary Language

Room/bed

Gender

|_| Female

|_| Male

Advance Directive

|_| Full Code

|_| No Code

|_| Meds Only

|_| No CPR

Precaution

|_| Contact Cdiff

|_| Standard

|_| Other

|_|

|_| Enteric

|_| Droplet

|_| Fall

|_|

|_| Neutropenic

|_| Airborne

|_| Aspiration

|_|

Primary Admitting Diagnosis

Secondary Diagnoses

Allergies

Vital Signs

Time

Time

BG

Blood pressure

Location /position

Heart Rate

Respiratory Rate

Temperature /route

SpO2

Oxygen delivery

NEURO

Orientation

|_| Person

|_| Place

|_| Time

|_| Disoriented

|_|

|_| Situation

|_| Verbal

|_| Non Verbal

Strength

LUE

RUE

LLE

RLE

Behavioral/Emotional

Moves Well Upon Request

|_|

|_|

|_|

|_|

|_|

Calm/cooperative

Weak Movement Upon Request

|_|

|_|

|_|

|_|

|_|

Restless

Moves Well When Stimulated

|_|

|_|

|_|

|_|

|_|

Combative

Weak Movement When Stimulated

|_|

|_|

|_|

|_|

|_|

Confused

No Movement

|_|

|_|

|_|

|_|

|_|

Agitated

Hearing

|_| Normal

|_| Loss

|_| Hearing aid

Eyes

|_| PERRLA

|_| Drainage

|_| Glasses

|_|

|_|

|_|

Dentures

|_| Full

|_| Partial

|_| Upper

|_| Lower

CARDIOVASCULAR

RATE

Heart Sounds

|_| S1S2

|_| Regular

|_| Irregular

|_| Murmur

|_| S3

|_| S4

Capillary Refil

|_| < 3 sec

|_| >3 sec

|_| absent

Pulses

RATE

Edema

Check one per column

ALL

LUE

RUE

LLE

RLE

ALL

LUE

RUE

LLE

RLE

Absent

|_|

|_|

|_|

|_|

|_|

Absent

|_|

|_|

|_|

|_|

|_|

Intermittent

|_|

|_|

|_|

|_|

|_|

Trace

|_|

|_|

|_|

|_|

|_|

+1

|_|

|_|

|_|

|_|

|_|

1+

|_|

|_|

|_|

|_|

|_|

+2

|_|

|_|

|_|

|_|

|_|

2+

|_|

|_|

|_|

|_|

|_|

+3

|_|

|_|

|_|

|_|

|_|

3+

|_|

|_|

|_|

|_|

|_|

Bounding

|_|

|_|

|_|

|_|

|_|

4+

|_|

|_|

|_|

|_|

|_|

Non pitting

|_|

|_|

|_|

|_|

|_|

Pitting

|_|

|_|

|_|

|_|

|_|

RESPIRATORY

RUL

LUL

LLL

RML

RLL

Rate

Clear

Additional comments

Rales

Crackles

Rhonchi

Wheeze

Diminished

Respiratory symptoms

cough

nonproductive

productive

Sputum

SOB

hypoventilating

hyperventilating

cyanosis

Use of accessory muscle

Dyspnea

Nasal drainage

other

GI

Bowels sounds

ALL

LUQ

RUQ

RLQ

LLQ

GI Symptoms

Present

|_|

|_|

|_|

|_|

|_|

|_|

Constipation

Hypoactive

|_|

|_|

|_|

|_|

|_|

|_|

Diarrhea

Hyperactive

|_|

|_|

|_|

|_|

|_|

|_|

Abd pain

Absent

|_|

|_|

|_|

|_|

|_|

|_|

Flatulence

|_|

Incontinence

Distention

|_|

|_|

|_|

|_|

|_|

|_|

Bloody stool

Tenderness

|_|

|_|

|_|

|_|

|_|

|_|

GU

Urinary Symptoms

Urine color

Character

Elimination

|_| Dysuria

|_| yellow

|_| clear

|_|

Voiding w/o difficulty

|_| Frequency

|_| amber

|_| cloudy

|_|

Voiding with difficult

|_| Oliguria

|_| orange

|_| concentrated

|_|

Indwelling catheter

|_| Polyuria

|_| brown

|_| sediment

|_|

Inability to void

|_| Anuria

|_| red

|_| bloody

|_|

Condom catheter

|_| Incontinence

|_| pink

|_| clots

|_|

Suprapubic catheter

|_| Hematuria

|_| odor

|_|

Urostomy

|_|

Nephrostomy tube

|_|

Dialysis

|_|

Ileal conduit

Output

Intake

Diet

|_| NPO

|_| Anorexia

|_| Nausea

|_| Vomiting

|_| Tolerate

|_| Dysphagia

|_| Other

IV lines

INTEGUMENTARY

Sensory Perception

Nutrition

Activity

Mobility

|_| Completely limited

|_| Poor

|_| Bedrest

|_| intact

|_| complete immobile

|_| Very limited

|_| inadequate

|_| OOB to chair

|_| redden

|_| limited

|_| Slightly limited

|_| Adequate

|_| BRP

|_|

|_| no limitations

|_| No impairment

|_| Excellent

|_| Ambulate

|_|

|_| Bruises

|_| Lesions

|_| Masses

|_| Wounds

MUSCULOSKELETAL

|_| pain

Pain Scale

Devices

|_| swelling

location

|_| walker

|_| stiffness

onset

|_| cane

|_| contractures

duration

|_|

|_| deformities

frequency

|_|

|_| weakness

Aggravating factor

|_| amputation

Alleviating factor

|_| fractures

Quality

|_| cast

ALL

LUE

RUE

LLE

RLE

Muscle strength

|_|

|_|

|_|

|_|

|_|

Full ROM

|_|

|_|

|_|

|_|

|_|

Impaired ROM

|_|

|_|

|_|

|_|

|_|

LABS

Pt Results

High/low

Reason for abnormality

Diagnostic tests /results

List of Problems can be actual, risk or potential with supporting subjective or objective data

1.

2.

3.

4.

5.

Nursing Diagnosis with supporting objective/subjective data

Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented)

Nursing actions to meet goals

Rational for each nursing action (EBP)

1.

2.

Evaluation of outcome

Educational Nursing Diagnosis with supporting objective/subjective data

Goal with expected outcome should be (S specific, M measurable, A achievable, R reality based, T time oriented)

Nursing actions to meet goals

Rational for each nursing action (EBP)

1.

2.

Evaluation of outcome

|_|

I have confirmed I have the right patient, drug, dose, route, and time.

If not administered,

Select a reason for not administering

|_|

I have completed my THREE checks (i.e. medication safety retrieved/pulled, when I am preparing/pouring the medication, and right before I give the medication to the patient)

1

Refused

2

NPO

3

Nauseated

4

Unable to swallow

5

Off unit

6

Wasted/ Dropped

7

Drug not available

8

Other

Patient Secondary ID Check

|_| Full name |_| Birth Date

Medication /classification

Dosage /route/ frequency

Reason for administration

Nursing consideration/

Side effects

Administer

Not

Administer

Enter code

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|

|_|