7/25/2021 Gmail – Case Study
https://mail.google.com/mail/u/0?ik=8c07fad849&view=pt&search=all&permthid=thread-f%3A1706308209533992067&simpl=msg-f%3A1706308209533992067 1/5
adepeju Abimbola-peters
Case Study
1 message
Zainab Alake
To: adepeju Abimbola-peters
NSG 110 Case Study for Concept Map #3
Mrs. NW is an 81-year old admitted to your rehabilitation center from the hospital for short term rehabilitation. She had hip replacement and is to
work with physical therapy to get her stronger so she can return home and care for herself.
During the admission, Mrs. NW tells you “I am so nervous about being here. If I don’t do well, they won’t let me go home by myself. I was so
used to caring for myself before I fell and broke my hip. This has been so hard. Except for some joint stiffness in the morning, I really don’t have
anything wrong with me and I am proud of that! I have never had to take any medications. It has been hard to deal with the pain and having to
take pain medication. I am very active in my church. I even volunteer at the senior center. Plus, I babysit my great-granddaughter who is 1. If I
don’t get back to my old self, I’m afraid I will lose my freedom to do these things. What if I fall again? I don’t want to be known as ‘old and
feeble.’ Only old people use walkers and canes.”
ViIndividual Care Map Evaluation Tool – NSG110 beginning May 2021
Identify, Organize. and analyze the
Assessment data from patient
chart/case study. (Organized into
subjective/objective data and by body
system)
Data organized
into subjective
and objective
data and by
body system.
90-100% of
data included.
(20 pts)
20 points
Data organized
into subjective
and objective
data and by
body system.
≤80% of data
included. (16
pts.)
16 points
Data organized
into subjective
and objective
data or data
organized by
body system.
90-100% of
data included
(12pts.)
12 points
Data not
organization
into subjective
and objective
data or by
body system. ≤
80% of data
included
(10pts.)
10 points
Data
disorganized
and/or ≤ 60%
included.
(5pts.)
5 points
No answer
0 points
Demonstrate appropriate use of Data is Data is Data is not Data analysis Data analysis Data clusters
7/25/2021 Gmail – Case Study
https://mail.google.com/mail/u/0?ik=8c07fad849&view=pt&search=all&permthid=thread-f%3A1706308209533992067&simpl=msg-f%3A1706308209533992067 2/5
Gordon’s Functional Patterns by
organizing data into meaningful data
clusters. Functional or dysfunctional
patterns correctly labeled. Each
Gordon’s pattern is defined and has a
citation
analyzed with
relationship to
Gordon’s
patterns;
clearly
identifies the
priority human
responses to
the health
situation. All
patterns are
defined with
citation.
Functional or
dysfunctional
patterns
correctly
labeled.
(20pts)
20 points
analyzed with
relationship to
Gordon’s
patterns;
clearly
identifies the
human
response
Concept map template
Nursing 110
Name:
Class:
Due Date:
Patient’s Initials:
Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box.
Body Systems Subjective Data Objective Data
Neurologic
HEENT (Head, Eyes, Ears, Nose, Throat)
Integument
Musculoskeletal
Cardiovascular
Respiratory
GI
GU
Emotional/Social/Spiritual
Reproductive
2
Step 2: Group the subjective and objective data that belong together in the same data cluster. Identify the correct Gordon’s Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed.
Clustered Data (all relevant)
Relevant Gordon Pattern: Health Perception/Health Management
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Sleep/Rest
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Sexuality/Reproductive
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Value/Belief
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Cognitive/Perception
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Elimination
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Nutrition/Metabolic
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Activity/Exercise
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern: Coping/Stress
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition:
Clustered Data (all relevant)
Relevant Gordon Pattern:
Role/Relationship
Definition:
Patient Name:
Age:
Gender:
Chief Complaint:
Clustered Data (all relevant)
Relevant Gordon Pattern (name, functional or dysfunctional):
Associated Nursing diagnostic label:
Patient Name:
Age:
Gender:
Situation:
Priority Nursing Diagnostic Statement:
Diagnostic Label
Related to
Evidence
Goal:
2-3 SMART outcomes:
1.
2.
3,
In your own words, based on the data cues, what is the most important (priority) problem?
List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3):
1.
Step 3: Type in the Data Clusters. Identify the Gordon’s Pattern and functionality; Analyze the data cluster to determine the problem. Identify the appropriate Nursing Diagnostic Label (nursing diagnosis). Complete the remaining sections. Include arrows showing how each data cluster/problem influences others on the care map. . Add, Expand, or Rearrange the boxes as needed.
Clustered Data (all relevant)
Relevant Gordon Pattern (name, function
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