Nursing

NSG110 Nursing Concept Map, Part I

Assessment Data by Body System
	Subjective data	Objective data
Neurological	The patient knew her age and has no immediate family history for breast cancer.	The patient seemed not concerned at all.
HEENT	Headache,	Neck Stiffness, lymph nodes are swollen,
Integumentary	Itchy skin and dry around breast area.	Skin is dry, intact, and warm to touch.
Musculoskeletal	No joint pain.	No joint swellings and shoulder range of motion smooth, symmetrical, and simultaneous
Cardiovascular	Chest pain	Apical pulse rate 85BPM,
Respiratory	Difficulty breathing, coughing.	Presence of cough, pleuritic pain, shortness of breath, and faint chest pains expressed.
GI	No nausea, no constipation.	No vascular abnormalities and gurgling bowel sounds every 5–10 sec.
GU	No painful urination	No difficulty in voiding.
Emotional/ Social /Spiritual	Loneliness, belief in God.	The patient is hopeful, tries to stay positive.
Reproductive	Lost interest in sex.	Patient has no children.

Step One: Select a client with a chronic illness. Identify the client demographics in the blue box. Gather all assessment data that pertains to the client and place each assessment finding in the chart under the appropriate body system and data category (subjective versus objective).

Patient Initials: SL

Age: 48

Gender: female

Primary Medical Diagnosis: Breast Cancer

Other Medical Diagnoses/Health Problems: Ductal carcinoma in situ (DCIS)

Step Two: Place the assessment findings from the chart on page one into data clusters in the appropriate Gordon Functional Pattern (GFP). An assessment finding may apply to multiple GFP’s.

Health Perception-Health Management Pattern: Cost of treatment, change of new lifestyle.

Sleep and Rest: Patient’s sleep pattern disturbed, anxious.

Sexuality-Reproductive Pattern: Sexual dysfunction, loss of interest, fatigue, Fear, anxiety.

Elimination Pattern: Bladder incontinent, bowel incontinent, fatigue.

Nutritional-Metabolic Pattern: Readiness for enhanced fluid nutrition and fluid balance, tissue integrity.

Cognitive Perceptual Pattern: Social isolation, knowledge deficit, fear, anxiety.

Activity-Exercise Pattern: Fatigue, self-care deficit, pain.

Self-Perception- Self Concept Pattern: depressed, fearful, powerless.

Value-Belief Pattern: health seeking behavior, Spiritual distress, belief in GOD.

Coping-Stress Tolerance Pattern: Denial, no risk for suicide, managing the disease.

Role-Relationship Pattern: Social isolation, loneliness, lose of interest in relationship.

References

Paans, W., & Müller‐Staub, M. (2015). Patients' care needs: Documentation analysis in general hospitals. International journal of nursing knowledge, 26(4), 178-186.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: Planning, individualizing, and documenting client care. FA Davis.