Concept map template Nursing 240/245/430 Patient Situation: Medical Dx/pathophysiology List doctors order medications Labs/xrays Pertinent Medical History Nursing 240/245/430 Page 1 Assessment Subjective /objective data Body Systems Gordon Pattern and cluster data Gordon Pattern and cluster data Gordon Pattern and cluster data Patient Gordon Pattern and cluster data Gordon Pattern and cluster data Nursing 240/245/430 Page 2 Intervention and rationale Evaluation Educational Nsg Dx Goal/outcome Psychosocial Nsg Dx Physiological Nsg Dx Goal/outcome Goal/outcome Intervention and rationale Intervention and rationale Evaluation Evaluation Nursing 240/245/430 Page 3   Write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume your instructor knows anything about your thought process, because they don’t. Show your instructor how you are thinking! How to begin……………. On a separate page: Include ALL of the questions with the Answers of the questions: In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.) Using Gordon’s as a guide, Explain which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph). List the identified nursing diagnoses in priority order the: “Problem” Related to “_____ “ Evidenced by “____” format. Which nursing diagnosis is most important to address with this client? Explain how this was determined. Which nursing diagnosis is second most important to address with this client? Explain how this was determined. Which nursing diagnosis is least important to address with this client? Explain how this was determined. Describe the evaluation of the client for each nursing diagnosis? Answer questions Nursing 240/245/430 Page 4 References (all in APA format) Nursing 240/245/430 Page 5 Patient Name: B.H DOB: 12/22/1957 Age: 64 y/o Preferred Language: English Code Status: Full Code Allergies: Iodine, Penicillin, Percocet, Oxycodone-Acetaminophen Situation: Medical Dx/ Pathophysiology: Peripheral Edema: clinical manifestation of an accumulation of fluid within the interstitial spaces of the body. It develops when the normal balance between the flow of fluid out of capillaries and the return of fluid to the vascular space via capillary reabsorption and lymphatic flow is disrupted. Labs/Xrays Vital Signs: BUN: 28 level high Glucose Test: 168 Hyperglycemic Calcium: Within Range Sodium: 137 Within Range Creatinine: 1.5 level high CO2: 28 Within Range Chloride: 102 Within Range Potassium: 4.1 Within ...

1. Concept map template
Nursing 240/245/430
Patient
Situation: Medical Dx/pathophysiology
List doctors order
medications
Labs/xrays
Pertinent Medical History
Nursing 240/245/430
Page 1
Assessment
Subjective /objective data
Body Systems
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Patient
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Nursing 240/245/430
Page 2
Intervention and rationale
Evaluation
Educational Nsg Dx
Goal/outcome

2. Psychosocial Nsg Dx
Physiological Nsg Dx
Goal/outcome
Goal/outcome
Intervention and rationale
Intervention and rationale
Evaluation
Evaluation
Nursing 240/245/430
Page 3
Write about what you just did and how you thought about it.
Each Gordon’s Patterns set shall be a paragraph. Tell me about
all the thinking you did to develop the associated nursing
diagnoses for that data cluster set. Then, move on to the next
data cluster and make that a new paragraph. Don’t assume your
instructor knows anything about your thought process, because
they don’t. Show your instructor how you are thinking! How to
begin…………….
On a separate page: Include ALL of the questions with the
Answers of the questions:
In separate paragraphs, explain the data clusters and which
Gordon’s pattern is represented by each data cluster. Which
Gordon’s patterns are Functional or Dysfunctional? (Take each
of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, Explain which nursing diagnoses are
identified for this client? (Separate each Gordon’s pattern into a
paragraph).
List the identified nursing diagnoses in priority order the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this
client? Explain how this was determined.
Which nursing diagnosis is second most important to address

3. with this client? Explain how this was determined.
Which nursing diagnosis is least important to address wi th this
client? Explain how this was determined.
Describe the evaluation of the client for each nursing diagnosis?
Answer questions
Nursing 240/245/430
Page 4
References (all in APA format)
Nursing 240/245/430
Page 5
Patient
Name: B.H
DOB: 12/22/1957
Age: 64 y/o
Preferred Language: English
Code Status: Full Code
Allergies: Iodine, Penicillin, Percocet, Oxycodone-
Acetaminophen
Situation: Medical Dx/ Pathophysiology:
Peripheral Edema:
clinical manifestation of an accumulation of fluid within the
interstitial spaces of the body. It develops when the normal
balance between the flow of fluid out of capillaries and the
return of fluid to the vascular space via capillary reabsorption
and lymphatic flow is disrupted.
Labs/Xrays
Vital Signs:
BUN: 28 level high
Glucose Test: 168 Hyperglycemic

4. Calcium: Within Range
Sodium: 137 Within Range
Creatinine: 1.5 level high
CO2: 28 Within Range
Chloride: 102 Within Range
Potassium: 4.1 Within Range
Medications
-Gabapentin(NEURONTIN) capsule 200mg oral every 8hrs for
neuropathic pain. Side effects of gabapentin are Feeling sleepy,
tired, dizzy, nausea, vomiting, diarrhea, Swollen arms and legs
and Blurred vision. (Burchum & Rosenthal, 2019).
-Aspirin Chewable tab 81mg, blood thinner salicylate and a
nonsteroidal anti-inflammatory drug (NSAID)
-Amlodipine (Norvasc) 2.5 mg, decreased blood pressure
-Hydralazine tablet 29mg
Atorvastatin QHS 80mg reduce LDL
Bumetanide 2 x day 0.5mg diuretic/urination
Bupropion BID 75mg antidepressant
Carvedilol BID 25mg antihypertensive, take with food 2 tabs a
day.
List of Doctors Order:
-Vital Sign: Q8
-Chest Xray
-Blood Glucose
-Echo Cardiogram Complete
-Lung Scan perfusion only
-US Vein Duplex UE Unilateral
Pertinent Medical History
-Chest Pian 12/28/18
-Syncope 12/28/18

5. -Cardiomyopathy 12/28/18
-Coronary Artery Disease 12/28/18
-DKA 1/28/20
-Altered Mental Status 1/28/20
-Metabolic Acidosis 1/30/20
-Peripheral Edema 3/23/22
-CVA 3/23/22
-TIA 3/23/22
-Lactic Acidosis 2/26/20
-Sever Sepsis 1/30/20
Nursing 240/245/430
Page 1
Assessment
Subjective: Patient has a pain to left upper and lower extremity,
two person assist patient today with ADL. Patient is allergies to
Penicillin's, respond verbally when asked, and patient was calm
and cooperative when providing care. patient BG was 123-
7:23am.
Objective data: 64/ y-o female diagnosis Peripheral Edema with
history of Pulmonary embolism, CVA, TIA.
Body System
Cardiovascular: Hr- 81, BP-175/78, Capillary refill is less than
3 second bilaterally, S1S2 present, it is a regular rate rhythm,
no murmur, rubs or gallops.
Respiratory: RR- 18,02-98%
Neurological: patient is alert and oriented to person, time,
place, and situation, Patient strength is 5/5 in the left upper
extremity upon inspection and ROM, but movement is affected
due to pain in left lower extremity. Eyes reacted to light, pupils
equal, round, reactive to light, and accommodation, intake and
output, no edema.
Integumentary: No Bruising noted, no rashes, Patient skin
warm, no wound noted, no redness, pain tenderness, swelling or
infiltration.

6. Musculoskeletal: Mild pain on the Patient has a pain to left
lower extremity.
GI: Bowels sounds was present in all four quadrants upon
auscultation. Soft, non-tender, not distended, no palpable
masses, normal active bowel sound, and no rebound or
guarding.
GU: Patient void w/o difficult. Patient is incontinence, Pt used
purewick , Patient output was 475cc and Patient intake was
236mL.
Gordon Pattern and cluster data
Elimination Pattern.
-Continent for bowel
-Incontinent for urine (pure wick)
Gordon Pattern and cluster data
Nutrition and Metabolic Pattern
No food allergies
No fluid restriction
Gordon Pattern and cluster data
Health perception and health management
-patient can make good health decisions for herself
-Risk for infection
Patient
Name: B.H
DOB: 12/22/1957
Age: 64 y/o
Preferred Language: English
Code Status: Full Code
Allergies: Iodine, Penicillin, Percocet, Oxycodone-
Acetaminophen
Gordon Pattern and cluster data
Cognitive-perceptive Pattern.
-chronic pain

7. Patient is consent about disturbed body image due to left lower
extremities no movement
NDx: Ineffective self-health management r/t age-related
malfunctions as evidence by patient age is 64, patient not being
able to care for self.
Gordon Pattern and cluster data
Sleep Rest pattern:
-normal sleeping pattern
Patient takes naps throughout the shift; patient reported no
difficulty sleeping patient seems relaxed.
Nsg Diagnosis: Readiness for enhanced normal sleep routines r/t
natural pattern of sleep as evidence by patient taking naps,
patient being relaxed, no report of difficulty falling asleep.
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Page 2
Intervention and rationale
Encourage mobility
- Manage pain
Evaluation
-Progressing
- Reposition q2
Educational Nsg Dx:
Deficient knowledge related to lack of understanding to detect
complications of impaired physical mobility as evidenced
limited movements
Goal/outcome:
Demonstrate behaviors to improve physical mobility by doing
some deep breathing every 8hr and ROM.
Psychosocial Nsg Dx:

8. Risk for activity intolerant as related to chronic pain
Physiological Nsg Dx
Risk for Venous Thrombosis Embolism as related to lack of
adequate mobility
Goal/outcome :
Verbalizes/displays adequate comfort level or baseline comfort
level
Goal/outcome
The goal is for venous thrombosis to be absence
Intervention and rationale:
Administer pain medication
Encourage patient to monitor pain and request assistance
Assess pain using appropriate pain scale
Administer analgesics base on type and severity of pai n and
evaluate response
Intervention and rationale:
Assist the patient to turn every 2 hours. If ambulatory, allow
patient to sit up on edge of bed as tolerated.
Evaluation:
Met: Patient has developed alternative ways to deal with stress
such as deep breathing technique, exercise to relieve stress.
Evaluation:
Met: Patient was able to understands and was able to state and
teach back 2 complications, signs, and symptoms.
Nursing 240/245/430
Page 3
Write about what you just did and how you thought about it.
Each Gordon’s Patterns set shall be a paragraph. Tell me about
all the thinking you did to develop the associated nursing

9. diagnoses for that data cluster set. Then, move on to the next
data cluster and make that a new paragraph. Don’t assume your
instructor knows anything about your thought process, because
they don’t. Show your instructor how you are thinking! How to
begin…………….
On a separate page: Include ALL of the questions with the
Answers of the questions:
In separate paragraphs, explain the data clusters and which
Gordon’s pattern is represented by each data cluster. Which
Gordon’s patterns are Functional or Dysfunctional? (Take each
of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, Explain which nursing diagnoses are
identified for this client? (Separate each Gordon’s pattern into a
paragraph).
List the identified nursing diagnoses in priority order the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this
client? Explain how this was determined.
Which nursing diagnosis is second most important to address
with this client? Explain how this was determined.
Which nursing diagnosis is least important to address with this
client? Explain how this was determined.
Describe the evaluation of the client for each nursing diagnosis?
Answer questions
Nursing 240/245/430
Page 4
On a separate page: Include ALL of the questions with the
Answers of the questions:
Health Perception and Health Management Pattern: patient is to
make health decision by himself. As such this Gordon’s patten

10. is functional. This has help me to understand that this patient
can make good health decision by himself, as such he does not
need any one to make healthy health managements for him in
other for him to live healthy.
-Nutrition and Metabolism Pattern: Patient is not on any food
restriction and is not allergy to any food. This Gordon’s pattern
is functional because this patient have good diet menu, no food
restriction regarding his disease, no food restriction regarding
religious point of vie, no food allergy, skin, scalp and nails are
clean and intact. This data have help me to understand that
because this patient is eating healthy that is why his skin, scalp,
nails are clean, healthy and intact
-Elimination Pattern: This patient is continent both bowel and
urine. This Gordon patten is functional. This data have help me
know that even though patient is in palliative care he can still
go to bathroom by himself.
-Cognition and Perception Pattern: patient is able to make
decision about herself, alert and orientated X four as such this
Gordon’s pattern is functional. This data have help me
understand that because even though this patient is on palliative
care, he still make good decisions concerning his health.
-Sleep and Rest Pattern: Patient sleep and rest pattern is within
defined limit. This Gordon pattern functional. This will help me
to know that I need to encourage patient to monitor pain and
request assistance because pain can disrupt his sleep and rest
pattern.
References:
Brown, D., Edwards, H., Buckley, T., & Aitken, R. L. (2020).
Lewis's medical-surgical nursing: Assessment and management
of clinical problems. Elsevier.
Hagler, D., Harding, M., Kwong, J., Roberts, D., & Reinisch, C.
(2020). Clinical companion to medical-surgical nursing:

11. Assessment and management of clinical problems. Elsevier.
Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's
pharmacology for nursing care. Elsevier.
Burchum, J. R., Rosenthal, L. D., Jones, B. O., & Neumiller, J.
J. (2016). Lehne's pharmacology for nursing care.
Elsevier/Saunders.
Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's
pharmacology for nursing care. Elsevier.
Burchum, J. R., Rosenthal, L. D., Jones, B. O., & Neumiller, J.
J. (2016). Lehne's pharmacology for nursing care.
Elsevier/Saunders.
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