NSG110 Nursing Concept Map, Part I Assessment

NSG110 Nursing Concept Map, Part I

Assessment Data by Body System
Subjective data Objective data
Neurological Client is not having any headache and dizziness, no changes in LOC (loss of consciousness) and no tingling sensations. She mentions no history of history of tremors or seizures. Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral strength is great
HEENT Head: No head injury, or change in LOC.
Eyes: Reported no changes in vision, diplopia or blurring of vision.
Ear: No pain in the ears and no loss of hearing or drainage.
Nose: No nasal drainage or congestion.
Throat: No throat or neck pain hoarseness and report no difficulty in swallowing. Head: head is normal, atraumatic, symmetric, no discomfort. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no color pigmentation, visual impairment, and eye movements intact. No uncontrolled eye movement noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
Integumentary Client said, “She has itching around the extremities and discomfort due to excessive hair growth and the abdomen”. Intact. Dry. Discoloration around the neck area. Excessive hair growth around the abdomen. There is presence of striae around the abdominopelvic region. No active wounds. No petechiae or purpura. No rashes. No cyanosis or jaundice.
Musculoskeletal Client said, “she has never fallen, currently experiencing no pain and not hearing a clicking or snapping sound.” No redness. No swelling. No pain to palpation. Active and passive range of motion (ROM) within normal limits, no stiffness.
Cardiovascular No chest pain, palpitation, tachycardia, orthopnea, or paroxysmal nocturnal dyspnea. S1S2, regular rate and rhythm, no murmur or gallop noted. .
Respiratory Client said“ she has no shortness of breath, cough or hemoptysis.(coughing blood)” No dyspnea or use of accessory muscles observed. No irregular sound heard during auscultation, tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GI Client reported frequent episodes of excessive thirst. And no history of heartburn, bloatedness, abdominal pain, nausea, vomiting, constipation, diarrhea, and melena. Striae and excessive hair growth around abdomin-pelvic region. No mass. Upon auscultation, there is normoactive bowel sounds present in all four quadrants. Abdomen soft non-tender, and no guarding.
GU Client reported polyuria and nocturia but no hematuria and dysuria and further mentioned no difficulty starting/stopping stream of urine or incontinence. Striae around the abdominal or flank area. No mass. No suprapubic tenderness. No bladder distention. No costovertebral angle tenderness.
Emotional/ Social /Spiritual Client mentioned sudden panic attacks, and anxiety when stressed. Discomfort because of being obese. Difficulty socializing outside the family circle due to shyness and low self-esteem. Has a great relationship with husband and children. Claims to be religious and attend church mass gatherings. Participate in bible studies. Patient wears clean, kept clothes. Patient’s height is not proportionate to its weight. Patient is cooperative. No tics, or choreiform movements. No signs of impending violence. Speech is relaxed, and answers spontaneously.
Reproductive Claims to have menarche at 12 and menopause at 50. No medications. No surgeries. No excoriations, ulcerations, mass on external genitalia. Discharge is whitish, non-purulent, non-malodorous. Hair is fine, and evenly distributed. Vagina is intact. No tenderness upon palpation.

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).
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

Reference
Ashelford, S., Raynsford, J., Taylor, V. (2019). Pathophysiology and Pharmacology in Nursing (2nd ed.). SAGE Publications, Inc.
Hinkle, J., Cheever, K. (2017). Brunner & Suddarth’s Textbook of Medical Surgical Nursing. (14th ed.). Wolters Kluwe
Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010 .(25th ed.). Print (The 5-Minute Consult Series).

NSG110 Nursing Concept Map, Part I

Assessment Data by Body System
Subjective data Objective data
Neurological
HEENT
Integumentary
Musculoskeletal
Cardiovascular
Respiratory
GI
GU
Emotional/ Social /Spiritual
Reproductive

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).
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.

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