NUR 4717 Advanced Care Management Concept Map
Name: __________________________ Date: __________
Client Initials: MR
Room: ICU 4B
Age: 53
Plan
care: Continue/revise/d
Sex:ofFemale
______________________________________________________________________________
Chief Complaint: SOB, chest pain
Weight: 79.545 kg
Height: 5T
Admitting Dx: CABG
Admitting Diagnosis: CABG
Medical Hx: Chemo radiation, cholecystectomy, sigmoid resection RT leg
Chronic Diseases: CHF, IBS,
skin graft, c-section x2, HTN, CHF, HCD, PE.
Dyslipidemia, HodgkinàLymphoma,
Hypothyroidism, Acoustic Neuroma,
Anxiety, Depression, HTN,
Chemo/radiation 2022.
Pathophysiology of Medical
(Client-specific)
Physical Assessment Data: see last page
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Prioritize
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Prioritize
Prioritize
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Key Problem/ND:
Subjective / Objective Data:
Key Problem/ND:
Subjective / Objective Data:
Key Problem/ND:
Subjective / Objective Data:
Maslow’s:
Maslow’s:
Maslow’s:
Diagnosis:
Potential Complications:
Nursing Diagnosis (1): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported by clientÊresponse; include plan of care %.g. revise,
continue, discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
Nursing Diagnosis (2): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included #ited & referenced)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported with evidences;
include plan of care %.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
Nursing Diagnosis (3): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included #ited & referenced)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported with evidences;
include plan of care %.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
References: (APA 6th Ed)
Physical Assessment Data:
Vital Signs:
T: 98.5
Pulse: 81
Resp: 15
BP: 81/51
I/O: 1480.00/800
Neurological Assessment
Alert and oriented: Yes
Facial Symmetry: Intact
Pupils equal and reactive: Yes
Tongue: Midline
Reflexes present: Yes
Generalized weakness: Present/exists.
Dizziness: None
Headache: None
Eye pain: None
Double Vision: None
Blurred Vision: None
Cardiovascular
Heart sounds: Normal
Jugular distention: None
Cardiac Monitor: Yes
Capillary Refill:
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