concept mapping

i

Concept Mapping: A CRITICAL-THINKING APPROACH TO CARE PLANNING

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Concept Mapping:A CRITICAL-THINKING APPROACH TO CARE PLANNING

Pamela McHugh Schuster, RN, PhDProfessor of NursingYoungstown State UniversityYoungstown, Ohio

F.A. Davis Company / Philadelphia

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F. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103www.fadavis.com

Copyright © 2002 by F. A. Davis Company

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Library of Congress Cataloging-in-Publication Data

Schuster, Pamela McHugh, 1953-Concept mapping : a critical-thinking approach to care planning / Pamela McHugh

Schuster.p. cm.

Includes bibliographical references and index.ISBN 0-8036-0979-5 (pbk.)1. Nursing. 2. Critical thinking. I. Title.

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This book is dedicated to nursing students

learning to organize patient-care planning and to provide effective nursing care,

and to the nursing students’ clinical faculty.

Also to my husband,

Fred,

and my children,

Luke, Leeanna, Patty, and Isaac.

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A NOTE ABOUT USAGE

To avoid both sexism and the constantrepetition of "he or she," "his or her," andso forth, masculine and feminine pro-nouns are used alternately throughout thetext.

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Preface

uring most of my 15 years as a clinical faculty member teaching founda-tions and medical-surgical nursing, I required my students to develop and

submit weekly care plans using a five-column format common in nursing pro-grams. I asked the students to complete as much of the care plan as possible be-fore clinical, to come well prepared to the clinical preconference, and to submit towhat some of them referred to as “Dr. Schuster’s Grilling.” The “grilling” consistedof me questioning them about their plans of care, which was highly frustrating forthem and for me because most students have trouble summarizing patient datasuccinctly and developing comprehensive care plans from data.

For example, I once asked my students to assess a patient who had a hip re-placement and to report the patient’s priority problems in clinical preconference.One student reported that the patient’s priority problem was a fever. I asked whatcaused the fever: Was it related to an infection in the surgical wound?, Was the pa-tient developing atelectasis and pneumonia?, Or was the patient dehydrated andsimply in need of fluids? The student could not tell. Consequently, she could notclearly determine what to do in response to the patient’s fever. Another studentstated that a priority problem was pain. I asked what caused the pain. Was it fromthe incision, from a backache caused by lying on the table for the procedure, orfrom a headache? Again, the student was not sure, so he had trouble determiningan appropriate response to the problem.

One day out of frustration—the grilling was going very poorly—I asked myeight clinical students to write the main reason the patient needed health care inthe center of a piece of paper and to arrange all of the patient’s problems aroundthat reason. I then told them to group all of the assessment data, the treatments,and the medications, as appropriate, under the problems they identified. The re-sults were amazing. The students became organized in their thinking about prob-lems and better understood the relationships in patient data. Once they betterdelineated specific problems, they were better able to discuss appropriate responsesto those problems. They were thinking critically and coming up with wonderfulideas regarding patient-care planning and implementation of effective care. Per-formance in the clinical setting quickly improved, and the students were verypleased with themselves and with the care they provided.

Not long afterward, I described my students’ success in care planning and clin-ical implementation to a colleague, who informed me that we were doing conceptmapping. A review of the literature on concept mapping confirmed that my col-league was correct. I had discovered nothing new. Concept mapping is based on

Preface

vii

D

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the typical way of teaching the nursing processand care planning in most programs. The prob-lem is that these care plans are lengthy to write,time consuming, and commonly copied directlyfrom a care planning book. They cannot realisti-cally be completed before patient care, they focuson one problem at a time, and they fail to ad-dress the patient as a whole. Students reportspending hours before and after clinical experi-ences writing care plans, and faculty reportspending hours grading care plans. I’m con-vinced that concept map care planning offers abetter way, and I wrote this book to help studentslearn to:

● Synthesize pertinent assessment data intocomprehensive concept maps.

● Develop holistic and comprehensive careplans with nursing interventions that corre-spond to primary health problems and asso-ciated nursing diagnoses.

● Effectively implement nursing care usingconcept map care plans and thus improveclinical performance.

Concept maps help both faculty and studentsto clearly see patient needs, become quickly or-ganized in thoughts and actions, and implementholistic care. They are practical, realistic, andtime-saving. They reduce paperwork and im-prove clinical performance. Most importantly,they enhance critical-thinking skills and clinicalreasoning because students can clearly and suc-cinctly visualize priorities and identify relation-ships in patient data.

Recently, the critical-care faculty with whom Iteach told me that they’ve started taping my stu-dents’ concept map care plans to patients’ bed-side stands so they can use the diagrams as thefocus of discussions between physicians, nurses,and students. Imagine a useful nursing care planthat both staff nurses and physicians favor, de-veloped by student nurses! I wish you all muchsuccess in planning and implementing nursingcare using this exciting new method of conceptmap care plans.

theories of learning and educational psychology.However, concept mapping is a new approach toteaching and learning about care planning in thehealth-care setting—an approach that nursingfaculty and students agree is most exciting. Con-cept mapping is a diagrammatic teaching andlearning strategy that allows students and facultyto visualize interrelationships between medicaldiagnoses, nursing diagnoses, assessment data,and treatments.

Before developing a concept map, the studentmust perform a comprehensive patient assess-ment. From the assessment data, the student de-velops a skeleton diagram of the patient’s healthproblems (Step 1). The student then analyzes andcategorizes specific patient assessment data (Step2) and indicates relationships between nursingand medical diagnoses (Step 3). In Step 4, the stu-dent develops patient goals, outcomes, and nurs-ing interventions for each nursing diagnosis.Step 5 is to evaluate the actual patient responseto each nursing intervention and to summarizeclinical impressions.

The result of Steps 1 through 4 is a holistic,comprehensive, and individualized plan of carethat can be completed before patient care takesplace. This visual map of problems and inter-ventions is a personal pocket guide to patientcare, and is the basis of nursing care discussionsbetween students and faculty. Further, conceptmap care plans can be consulted throughout theclinical day, at the bedside, in the medicationpreparation area, and when preparing documen-tation. Concept map care planning evalua-tions have been excellent from both studentsand faculty.

This method of care planning is an alternativeto the commonly used column format, whichtypically includes subjective and objective assess-ment data, nursing diagnoses, patient and familygoals and outcomes, nursing interventions, ratio-nales for the interventions, and evaluation ofoutcome objectives and goals. Nursing programsmay vary slightly in what goes in each column,but until recently, the column format has been

viii PREFACE

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Reviewers

Emily Droste-Bielak, RN, BSN, MS, PhDAssociate ProfessorGrand Valley State UniversityAllendale, Michigan

Linda Lea Kelly Brown, RN, BSN, MA, MS, FNP-CProfessorNew Hampshire Community Technical CollegeClaremont, New Hampshire

Sybil W. Damon, RN, MS, DBAVN Program DirectorSummit Career CollegeColton, California

Dorcas C. Fitzgerald, RN, MSN, DNScProfessor and RN Track CoordinatorDepartment of NursingYoungstown State UniversityYoungstown, Ohio

Joan Fleitas School of NursingFairfield UniversityFairfield, Connecticut

Carole Heath, RN, BSN, MSN, EdD, PHNProfessorSonoma State UniversityRohnert Park, California

Denise Landry, RN, MSN, EdD, FNPProfessor, College of Nursing and HealthProfessionsMarshall UniversityHuntington, West Virginia

Bonnie Raingruber, RN, MS, PhDProfessor of NursingCalifornia State UniversitySacramento, California

Barbara Ann Ross, RN, ASN, BSN, MSN, EdDAssistant Professor and Web-developerIndiana School of NursingIndianapolis, Indiana

Peggy Wros, RN, BSN, MSN, PhDAssociate ProfessorLinfield CollegePortland, Oregon

ix

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Contents

1 ’Twas the Night Before Clinical . . . 1

2 Gathering Clinical Data: The Framework for Concept Map Care Plans 19

3 Concept Mapping: Grouping Clinical Data in a Meaningful Manner 45

4 Nursing Interventions: So Many Problems, So Little Time 71

5 Nursing Implementation: Using Concept Map Care Plans in the Health-Care Agency 89

6 Mapping Psychosocial Problems 103

7 Concept Maps as the Basis for Documentation 131

8 When the Clinical Day is Over: Patient Evaluations and Self-Evaluations 147

A P P E N D I C E S

A Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs 159

B Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns 161

C North American Nursing Diagnosis Association’s Nursing Diagnosis Categories 163

xi

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1

’Twas the Night Before Clinical . . .

O B J E C T I V E S

1. Define concept map care plans.

2. List the purposes of concept map care plans.

3. Identify the theoretical basis for clinical concept maps.

4. Relate critical-thinking processes to the nursing process and to concept map careplans.

5. Identify steps in the concept map care planning process.

6. Describe how concept map care planning corresponds to the nursing process.

7. Identify how concept map care plans are used during patient care.

8. Describe the purpose of standards of care as related to care planning.

9. List health-care providers and agencies responsible for developing and enforcingstandards of care.

10. Describe the purpose of managed care.

was the night before clinical and all through the house, not a

creature was stirring . . . except for you! There you are with books

piled high around you trying to get ready to give safe and competent

nursing care to the patients you have been assigned in the morning. It is

late, and you are tired. What if there were a way for all the information you

have gathered on your patients to just “come together,” make perfect sense,

and form a simple, complete care plan? If you have ever found yourself in

this situation, this book is for you. It was written to help you quickly and

efficiently organize and analyze patient data and develop a working care

plan. The plans you develop will be practical and realistic; they will be

implemented and evaluated during the clinical day. And best of all, there

Chapter 1Chapter 1

T’

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is very little writing to do! No more tedious writ-ing of nursing care plans!

The purpose of this chapter is to describe thetheoretical basis for concept map care plans andto provide an overview of what concept mapcare plans are, how they are developed, and howthey are used during patient care. In addition,the chapter introduces general standards forguiding and evaluating patient care within man-aged care systems. Managed care principles areused in almost all health-care delivery systems.The purpose of managed care is to decrease costswhile maintaining the quality of health-care ser-vices. The implications of managed care regard-ing care planning are far-reaching, and theyguide the development of nursing care plans.Later chapters will lead you step by step througheach aspect of developing and using conceptmap care plans.

WHAT ARE CONCEPT MAP CARE PLANS?

The concept map care plan is an innovative ap-proach to planning and organizing nursing care.In essence, a concept map care plan is a diagramof patient problems and interventions. Yourideas about patient problems and treatments arethe “concepts” that will be diagrammed. In thisbook, the term concept means idea. You will dia-gram your ideas about the patient’s problems andtheir treatments. Developing clinical conceptmap care plans will enhance your critical think-ing skills and clinical reasoning because you willclearly and succinctly visualize priorities andidentify relationships in clinical patient data.Concept map care plans are used to organize pa-tient data, analyze relationships in the data, es-tablish priorities, build on previous knowledge,identify what you do not understand, and enableyou to take a holistic view of the patient’s situa-tion.

THE THEORETICAL BASIS OF CONCEPT MAP CARE PLANNING

Concept map care plans have roots in the fieldsof education and psychology.1,2 Concept maps

2 CHAPTER 1 ’TWAS THE NIGHT BEFORE CLINICAL

have also been called cognitive maps, mindmaps, and meta-cognitive tools for teaching/learning.3,4 Nursing educators have recognizedthe usefulness of this teaching/learning strategyin summarizing and visualizing important con-cepts, and there is a growing body of knowledgeon this topic.5-9

From the field of education, Novak andGowin10 developed the theory of meaningfullearning and have written about “learning howto learn.” They have theoretically defined con-cept maps as “schematic devices for representinga set of concept meanings embedded in a frame-work of propositions.” They further explain con-cept maps as hierarchical graphical organizersthat serve to demonstrate the understanding ofrelationships among concepts. This theoreticaldefinition and explanation is highly abstract.Simply stated, concept maps are diagrams of im-portant ideas that are linked together. The im-portant ideas you need to link are patientproblems and treatments for those problems.

The educational psychologist Ausubel11 hasalso contributed to the theoretical basis of con-cept mapping through the development of assim-ilation theory. Concept maps help those whowrite them to assimilate knowledge. The premiseof this theory is that new knowledge is built onpreexisting knowledge structures, and new con-cepts are integrated by identifying relationshipswith those concepts already understood. Simplystated, we build and integrate new knowledgeinto what we already know. Through diagram-ming in a concept map, you build the structure ofwhat is known about the relationships in a con-cept. Thus, concept maps help to identify and in-tegrate what you already know. In addition,concept maps can help reveal what you do notunderstand. This means that although you haveideas about patient problems or treatments, youmay not be sure of how those problems and treat-ments should be integrated into a comprehensiveplan. Once you recognize what you do not un-derstand and can formulate questions, you canseek out information. Concept maps will helpidentify what you know about patient care andwhat you need to learn to provide quality care.

Concept mapping requires critical thinking. Awidely accepted view of critical thinking bymany nurse educators was developed by the


American Philosophical Association: “Criticalthinking is the process of purposeful, self-regulatory judgment. This process gives reasonedconsideration to evidence, contexts, conceptual-ization, methods, and criteria.”12 In developing aclinical concept map care plan, critical thinkingis used to analyze relationships in clinical data.Thus, critical thinking used in developing con-cept map care plans builds clinical reasoningskills. Critical thinking and clinical reasoning areused to formulate clinical judgments and deci-sions about nursing care.

Although concept maps have been used in anumber of different ways in various disciplinesincluding nursing, the focus of this book is ondeveloping concept maps for the purposes ofclinical nursing care planning. The importantideas that must be linked together during clinicalcare planning are the medical and nursing diag-noses, along with all pertinent clinical data. Con-cept map care planning can be used to promotecritical thinking and clinical reasoning about patient problems and treatment of problems.Through concept mapping of diagnoses and clin-ical data, you can evaluate what you know aboutthe care of a patient and what further informa-tion you need to provide safe and effective nurs-ing care. The visual map of relationships amongdiagnoses allows you and your clinical faculty to exchange views on why relationships existamong diagnoses. It also allows you to recognizemissing diagnoses and linkages, thus suggestinga need for further learning.

OVERVIEW OF STEPS IN CONCEPT MAP CARE PLANNING

The nursing process is foundational to develop-ing and using the concept map care plan or anyother type of nursing care plan. The nursingprocess involves assessing, diagnosing, planning,implementing, and evaluating nursing care.These steps of the nursing process are related tothe development of concept map care plans andthe use of care plans during patient care in clini-cal settings. Subsequent chapters will give the de-tails of concept map care planning with learningactivities, but it is important for you to have aninitial overview.

Preparation for Concept Mapping

Before developing a concept map, the first thingyou must do is gather clinical data. This step cor-responds to the assessment phase of the nursingprocess. You must review patient records to de-termine current health problems, medical histo-ries, physical assessment data, medications, andtreatments. This assessment must be completeand accurate because it forms the basis for theconcept map. Some of you may have the oppor-tunity to briefly meet patients the night beforeyou care for them. In just five minutes of inter-acting with a patient—even by simply intro-ducing yourself and watching the patient’sresponse—you can gain a wealth of informationabout the patient’s mood, level of comfort, andability to communicate. Chapter 2 will focus onhow to gather this clinical data in preparation fordeveloping a concept map.

Step 1: Develop a Basic Skeleton Diagram

Based on the clinical data you collect, you begin a concept map care plan by developing a basicskeleton diagram of the reasons your patient needshealth care. The initial diagram is composed ofclinical impressions you make after reviewing allof the data. Write the patient’s reason for seekingcare (usually a medical diagnosis) in the middle ofa blank sheet of paper. Then, around this centraldiagnosis, arrange general problems (nursing diag-noses) that represent patient responses to the pa-tient’s specific reason for seeking health care asshown in Figure 1–1. The general problem state-ments will eventually be written as nursing diag-noses as shown in Figure 1–1.13

The American Nurses Association (ANA) SocialPolicy Statement14 indicates that the focus ofnursing practice is on human responses to healthstates. The map reflects the ANA practice policystatement because the human responses are lo-cated around the health state of the patient.Nursing care will be focused on the human re-sponses.

The central figure of the map is whatever reason the patient is seeking health care—thereason for the hospitalization, extended care, orvisit to the outpatient center. In Figure 1–1, thehealth problem for which a patient seeks care,

’TWAS THE NIGHT BEFORE CLINICAL CHAPTER 1 3


the medical diagnosis, is centrally located on themap. However, the central figure may not alwayscontain a medical diagnosis: Sometimes the fo-cus of a visit may be on high-level wellness,when the patient will be seen for a screening ex-amination, and the aim is to maintain wellnessand prevent problems.

The map is primarily composed of nursing di-agnoses resulting from the health state, flowingoutward from the central figure like spokes on awheel. The map focuses strictly on real nursingcare problems based on collected data. It doesnot focus on potential problems. At this stage ofcare planning, it is most important to recognizemajor problem areas. You do not have to statethe nursing diagnosis yet. Write down your gen-eral impressions of the patient after your initialreview of data.

Labeling the correct diagnosis is difficult formany students. However, at this point, it is moreimportant to recognize major problem areas thanto worry about the correct nursing diagnostic la-bel. If you recognize that the patient has a majorproblem breathing, write it down. You are tryingto get the big picture here. Later, you can look upthe correct nursing diagnostic label and decide if the diagnosis should be Impaired Gas Ex-

change, Ineffective Airway Clearance, orIneffective Breathing Patterns. Initially, justwrite, in whatever words come to mind, whatyou think are the patient’s problems. Recogniz-ing that something is wrong with the patient ismore important than applying the correct label.Step 1 on formulating basic diagrams of prob-lems will be expanded on in Chapter 3.

Step 2: Analyze and Categorize Data

In this step, you must analyze and categorizedata gathered from the patient’s medical recordsand your brief encounter with the patient. Bycategorizing the data, you provide evidence tosupport the medical and nursing diagnoses. Youmust identify and group the most important as-sessment data related to the patient’s reason forseeking health care. You must also identify andgroup clinical assessment data, treatments, med-ications, and medical history data related to thenursing diagnoses, as shown in Figure 1–2.15

In this example of a concept map, you see thenursing diagnoses flowing outward from the pa-tient’s reason for seeking health care. Listedwithin each nursing diagnosis is the clinical evi-dence of problems that led the creator of the mapto conclude that the diagnosis was important forthat patient at that time.

Thus, when making a concept map care plan,you must write important clinical assessmentdata, treatments, medications, and medical his-tory data related to each nursing diagnosis. Thisinvolves sifting through and sorting out the often-voluminous amount of data that you col-lected on your patient. The sicker the patient, themore complex the analysis. You need to list as-sessment data regarding physical and emotionalindicators of problems or symptoms under theappropriate diagnoses. For example, physical in-dicators of problems from the data include la-bored respirations at a rate of 22, fatigue, anddecreased breath sounds. These are listed underthe nursing diagnosis Impaired Gas Exchange.Emotional indicators of problems include the pa-tient crying and verbalizing that he is nervousand saying that he knows he is going to die.These are listed under the nursing diagnosisAnxiety.


Figure 1–1Nursing and medical diagnoses.

Nutrition/Fluid and Electrolyte Imbalance

Pain Anxiety

Infection/Skin Integrity

DecreasedCardiac Output

ImpairedGas Exchange/

Oxygenation

Elimination Immobility

Reason for Seeking Health Care:Abdominal Abscess/Bowel Obstruction/

Post-op



Nutrition/Fluid and Electrolyte Imbalance

• NPO • Mystatin• Mouth ulcers • FBS = 147 (history of diabetes)• NG tube • Dry skin• TPN • Anemic• IV • Weakness• 139 lb, 5' 10"

Impaired Gas Exchange/Oxygenation• Ca of lung (history)• Radiation/chemotherapy (history)• Respiratory treatments• Decreased breath sounds rt lung• Incentive spirometry• Respirations labored check q4h• RT = q4h, Ventalin (albuterol)• RR = 22• Oxygen = 5 L• Hgb = 10• Fatigued

Pain• Abdominal abscess—

surgical wound• Mouth ulcers• Ca of bone/ lung with

chronic pain• Demoral (meperidine)• Morphine

Anxiety• Surgery• Says he knows he’s

going to die• Clenches his fists when

he can’t do something• Chronic pain• Fidgets with his hands• Cries• Verbalized that he is

nervous

Impaired Skin Integrity/Infection

• T = 100.5°F• Abscess—wound• 2 drains, purulent drainage• Fecal material in drain• WBC = 12.9

Decreased Cardiac Output

Reason for Seeking Health Care:Abdominal Abscess/ Bowel Obstruction/ Post-op

Priority Assessments: Pain, Distention,Bowel Sounds, I&O, Drainage, and Wound

Immobility• Ca of bone (history)• Chemotherapy (history)• Fall protocol• Lethargic/fatigued• Tubes (tripping)• Plexipulses

Elimination• Foley• Check urine output

>60 cc/h• Enlarged prostate• Proscar (finasteride)• Creatinine = 5• BUN = 22

• Atrial Fibrilation • Lanoxin• Vitals = q4h (digoxin)• Rate = 128 • PT = 17.5

(irregular) • PTT = 40.2• BP = 113/60 • Fatigue• K = 3.3

Figure 1–2Data to support diagnoses. Ca � cancer; BP � blood pressure; BUN � blood urea nitrogen; FBS � fastingblood sugar; Hgb � hemoglobin; I&O � intake and output; IV � intravenous; K � potassium; NG � nasogastric; NPO � nothing by mouth; PT � prothrombin time; PTT � partial thromboplastin time; RR � respiratory rate; RT � respiratory therapy; T � temperature; TPN � total parenteral nutrition;WBCs � white blood cells.


You must also list current information on diag-nostic test data, treatments, and medications un-der the appropriate nursing diagnoses. You mayneed to look up the diagnostic tests, treatments,and medications if you are not familiar withthem. You must think critically to place diagnos-tic test data, treatments, and medications underthe appropriate category. For example, diagnostictests include blood studies of white blood cells,hemoglobin, and potassium. In this case, thewhite blood cells are listed with Infection, thehemoglobin with Oxygenation, and the potas-sium with Decreased Cardiac Output. Oxy-gen and respiratory treatments are categorizedwith Impaired Gas Exchange. The medicationDemerol (meperidine) is categorized with Pain,while Ventolin (albuterol) is categorized with Im-paired Gas Exchange, and Lanoxin (digoxin)with Decreased Cardiac Output.

You must also list medical history informationunder the nursing diagnoses. In this example,the patient has a history of bone and lung can-cer, atrial fibrillation, and an enlarged prostate.The bone and lung cancer history is listed underthe nursing diagnoses of Pain, Gas Exchange,and Immobility; atrial fibrillation is under De-creased Cardiac Output, and the enlargedprostate is listed under Elimination.

When beginning to use concept maps withmedical and nursing diagnoses that are new toyou, you may not always know where to catego-rize an abnormal symptom, laboratory value,treatment, drug, or history information. If youdo not know where the data should go but youthink it is important, list it off to the side of themap and ask for clarification from your clinicalfaculty. At least you recognized it was important;you do not yet have the experience to see wherethe data fits in the overall clinical picture of pa-tient care.

Sometimes you may think that symptoms ap-ply to more than one nursing diagnosis, and theyoften do. You may recognize that the patient is lethargic and fatigued, but that observationcould go under Decreased Cardiac Output,Immobility, Nutrition, or Decreased GasExchange. It makes sense to place this symp-tom in more than one area. Therefore, you canrepeat a symptom in different categories if it isrelevant to more than one category.

Finally, determine the priority assessmentsthat still need to be performed regarding the pri-mary reason for seeking care (the primary med-ical diagnosis); write them in the box at thecenter of the map as shown in Figure 1–2. Thesepriority assessments must be done on first con-tact with the patient and carefully monitoredthroughout the clinical day. Focus on the key ar-eas of physical assessment that must be per-formed to ensure safe patient care. This step inthe concept map care planning process appearsin detail in Chapter 3.

Step 3: Analyze Nursing Diagnoses Relationships

Next, you need to analyze relationships amongthe nursing diagnoses. Draw lines between nurs-ing diagnoses to indicate relationships as shownin Figure 1–3.17 In this example, pain is relatedto Anxiety, Immobility, Infection, and Nu-trition. Be prepared to verbally explain to yourclinical faculty why you have made these linksif it is not obvious. For example, why pain andnutrition? In this case, the explanation is thatthe patient has mouth ulcers and an uncom-fortable nasogastric tube, contributing to pain.You will soon recognize that all the problemsthe patient is having are interrelated. You andyour clinical faculty can see the “whole picture”of what is happening with the patient by look-ing at the map. Thus, concept mapping is aholistic approach to patient care. Step 3 focuseson the relationships between diagnoses and thelabeling of nursing diagnoses according to theNorth American Nursing Diagnosis Associationclassification system (see Appendix C). These issues will be expanded upon in Chapter 3. Also, you will number each nursing diagnosison the map.

Step 4: Identifying Goals,Outcomes, and Interventions

Then, on a separate sheet of paper, you will writepatient goals and outcomes and then list nursinginterventions to attain the outcomes for each ofthe numbered diagnoses on your map. This step,which corresponds to the planning phase of thenursing process, is shown in the first column ofBox 1–1.18




Imbalanced Nutrition/Deficient Fluid Volume1

• NPO • Mystatin• Mouth ulcers • FBS = 147 (history of diabetes)• NG tube • Dry skin• TPN • Anemic• IV • Weakness• 139 lb, 5' 10"

Impaired Gas Exchange/Oxygenation5

• Ca of lung (history)• Radiation/chemotherapy (history)• Respiratory treatments• Decreased breath sounds rt lung• Incentive spirometry• Respirations labored check q4h• RT = q4h, Ventalin (albuterol)• RR = 22• Oxygen = 5 L• Hgb = 10• Fatigued

Pain2

• Abdominal abscess—surgical wound

• Mouth ulcers• Ca of bone/ lung with

chronic pain• Demoral (meperidine)• Morphine

Anxiety8

• Surgery• Says he knows he’s

going to die• Clenches his fists when

he can’t do something• Chronic pain• Fidgets with his hands• Cries• Verbalized that he is

nervous

Impaired Skin Integrity/Infection

3

• T = 100.5ºF• Abscess—wound• 2 drains, purulent drainage• Fecal material in drain• WBC = 12.9

Decreased Cardiac Output7

• Atrial Fibrilation • Lanoxin• Vitals = q4h (digoxin)• Rate = 128 • PT = 17.5

(irregular) • PTT = 40.2• BP = 113/60 • Fatigue• K = 3.3

Reason for Seeking Health Care:Abdominal Abscess/ Bowel Obstruction/ Post-op

Priority Assessments: Pain, Distention,Bowel Sounds, I&O, Drainage, and Wound

Impaired PhysicalMobility

6

• Ca of bone (history)• Chemotherapy (history)• Fall protocol• Lethargic/fatigued• Tubes (tripping)• Plexipulses

Impaired UrinaryElimination

4

• Foley• Check urine output

>60 cc/h• Enlarged prostate• Proscar (finasteride)• Creatinine = 5• BUN = 22

Figure 1–3Relationships between diagnoses. Ca � cancer; BP � blood pressure; BUN � blood urea nitrogen; FBS � fasting blood sugar; Hgb � hemoglobin; I&O � intake and output; IV � intravenous; K � potassium;NG � nasogastric; NPO � nothing by mouth; PT � prothrombin time; PTT � partial thromboplastin time;RR � respiratory rate; RT � respiratory therapy; T � temperature; TPN � total parenteral nutrition;WBCs � white blood cells



Box 1–1 P H Y S I C A L A N D P S Y C H O S O C I A L R E S P O N S E S

Problem No. 1: Imbalanced Nutrition, Imbalanced Fluid VolumeGoal: Improve nutrition

Outcome: Patient’s NG, TPN, and JP drains will remain patent, and patient’s intake of fluids andelectrolytes will balance outputs.

STEP 4 STEP 5Nursing Nutrition/Fluid Interventions Patient Responses (Evaluation)1. Assess new lab values 1. No new lab values except as shown below2. Assess I&O 2. Intake 600/ Output 6503. NPO 3. NPO except ice and medications4. Mouth care with nystatin mouth wash 4. Liked the taste, said it helped a lot5. Ice chips 5. Sucked on for sore throat6. Monitor NG tube, check drainage 6. Nurse checked (skill not yet learned)7. Monitor TPN 7. Nurse checked (skill not yet learned)8. Assess FBS 8. 109 at 6 A.M.9. Assess abdominal pain 9. Grimacing, moaning, “5”

10. Morphine for pain 10. Gave MS at 8:40; “2” at 9:1511. Bowel sounds 11. Hypoactive12. Distention 12. None, soft (has NG tube)13. Skin turgor 13. Poor, dry. Lubricated with bath14. Drainage, JP 14. Purulent yellow, foul-smelling A� and purulent

green B�

Impressions: Nutritional status in balance with intake equal to output, electrolytes stable, tubes remain patent, bowels remain hypoactive.

Problem No. 2: PainGoal: Control pain

Outcome: Patient’s pain remains below 3 on a 10-point scale.

STEP 4 STEP 5Nursing Pain Interventions Patient Responses (Evaluation)1. Assess pain with scale and medicate with 1. As above2. Demerol (meperidine) and morphine 2. � �3. Positioning 3. Positioned with pillow in bed4. Check noise, lighting 4. Decreased light and fell asleep5. Guided Imagery 5. Visualized a beach6. Backrub 6. Stated it hurt to be touched

Impressions: Patient needs narcotics to control pain and likes the nondrug measures of positioning, noise and light control, and guided imagery.


(Continued)

Box 1–1 P H Y S I C A L A N D P S Y C H O S O C I A L R E S P O N S E S (C O N T I N U E D )

Problem No. 3: Infection, Impaired Skin IntegrityGoal: Prevent further infection

Outcome: The patient’s infection will not get any worse and temperature will remain WNL.

STEP 4 STEP 5Nursing Infection Control Interventions Patient Responses (Evaluation)1. Monitor temperature 1. 96.2°F at 8 A.M., 97.9°F at 12 P.M.2. Assess WBC 2. No new values3. Bed bath 3. Cooperated but had pain as above4. Check skin integrity 4. No signs of additional breakdown5. Clean Foley 5. Patent, skin pink, and intact6. Oral care 6. Mouth sores; used nystatin7. Assess wounds, drains 7. Intact, no redness or edema—drains above

Impressions: Drainage from drains looks purulent, although incision intact without s/s of infection, temperature WNL

Problem No. 4: Impaired Urinary EliminationGoal: Maintain elimination

Outcome: The urine output will be �60 cc/h.

STEP 4 STEP 5Nursing Elimination Interventions Patient Responses (Evaluation)1. Call physician if urine output �60 cc/h 1. �60 cc/h2. Check Foley patency 2. Patent, draining3. Check color, amount, smell 3. Clear, yellow, no smell4. Clean Foley 4. As above5. Bedpan for BMs 5. None6. I&O 6. As above7. Monitor BUN, creatinine 7. No new labs drawn

Impressions: Patient’s elimination maintained above 60 cc/h.

Problem No. 5: Impaired Gas ExchangeGoal: Maintain oxygenation

Outcome: Patient cooperates with RT, uses oxygen, and breathing remains nonlabored.

STEP 4 STEP 5Nursing Oxygenation Interventions Patient Responses1. Monitor breath sounds 1. Rales throughout especially rt base2. Check VS, especially respirations 2. 8 A.M. 156/80; 96.2°F; 112; 20

12 P.M. 126/58; 97.4°F; 88; 203. Do CDB with respiratory therapist (RT) 3. RT did CDB after treatments4. Oxygen intact 4. Tolerated well

On at 5 L5. Fatigue 5. See immobility6. Monitor Hgb 6. No new labs

Impressions: Breathing nonlabored but remains congested, cooperative with treatments, elevations in BP and pulse probably due to pain as above.



Box 1–1 P H Y S I C A L A N D P S Y C H O S O C I A L R E S P O N S E S (C O N T I N U E D )

Problem No. 6: Impaired Physical MobilityGoal: Maintain movements

Outcome: Patient performs ROM, gets up to chair, remains free from injury.

STEP 4 STEP 5Nursing Mobility Interventions Patient Responses (Evaluation)1. Monitor fatigue 1. Weak and tired2. Safe environment (fall protocol) 2. Personal items in reach3. Side rails, bed low, call bell in reach 3. At all times4. Compression devices on in bed 4. On for 2 h5. Do ROM 5. Did ROM with bath6. Get up in chair at bedside 6. Up for 1 h and became fatigued

Impressions: Got up for an hour but is weak and tired. Performed ROM. High potential for a fall due to weakness and fatigue.

Problem No. 7: Decreased Cardiac OutputGoal: Maintain cardiac output

Outcome: Pulse and BP remain stable and electrolytes WNL.

STEP 4 STEP 5Nursing Cardiac Output Interventions Patient Responses (Evaluation)1. Check VS q4h, especially BP and P 1. As above2. Apical check with digoxin (Lanoxin) 2. 112 at 10 A.M.3. Check K 3. K � 3.84. Listen for arrythmias 4. None noted

Impressions: BP and P elevations probably due to pain; CV system appears stable.

Problem No. 8: AnxietyGoal: Decrease anxiety

Outcome: Patient verbalizes concerns.

STEP 4 STEP 5Nursing Anxiety Interventions Patient Responses (Evaluation)1. Guided imagery 1. States that it is relaxing2. Therapeutic communication, especially 2. Verbalized concerns

empathy, distraction, active listening3. Comfort touch 3. Held my hand when talking4. Teach slow deep-breathing 4. Appeared more relaxed, less grimacing

Impressions: Patient responded to anxiety interventions by verbalizing concerns.

Key: BUN � blood urea nitrogen; BM � bowel movement; CDB � cough and deep breathing; FBS � fasting bloodsugar; JP � juvenile periodontitis; NG � nasogastric; P � pulse; ROM � range of motion; TPN � total parenteral nu-trition; VS � vital signs; WBCs � white blood cells; WNL � within normal limits.


You must list the nursing care you intend toprovide for the patient during the time that youare scheduled to be interacting with the patient.You will carry the map and list of interventionsin your pocket as you work with the patient, and you will either check off interventions asyou complete them or make revisions in the di-agram and interventions as you interact with thepatient. The map and interventions are usedduring the intervention phase of the nursingprocess.

The nursing interventions include key areas ofassessment and monitoring as well as proceduresor other therapeutic interventions such as pa-tient teaching or therapeutic communication. Todecrease paperwork, the goals and rationales forinterventions are not written down. Come pre-pared to verbally explain the goals and rationalesfor your identified nursing actions if asked byyour clinical faculty. It is of course a professionalresponsibility to know why you are doing eachaction, even though you are not writing it down.

Be prepared to review nursing interventionsduring clinical pre-conferencing. Nursing inter-ventions include what you are supposed to becarefully monitoring. In addition, nursing inter-ventions should include a list of all appropriatetreatments and medications. Patient teachingshould be listed under nursing interventions asappropriate for each problem. For example, pa-tient teaching may involve slow, deep breathingand guided imagery under the nursing diagnosisAnxiety.

If you have not yet learned how to perform atreatment but you know the treatment needs tobe done, list it in the nursing intervention col-umn, and also note that the nurse assigned tooversee the patient’s care will be doing the treat-ment. For example, under nutrition, you maywrite that the patient needs total parenteral nu-trition and care of the nasogastric tube, but thatthese services will be done by the staff nursesince you have not yet learned how to providethem. By writing down the treatments in the ap-propriate column, you demonstrate that youhave recognized these nutrition-related treat-ments and that they are important aspects of thetotal care needed by the patient. Be prepared todiscuss the basic purpose of the interventions,even those you do not perform yourself. Step 4

on outcomes and nursing interventions will beexpanded on in Chapter 4.

Step 5: Evaluate Patient’s Responses

This step is the written evaluation of the pa-tient’s physical and psychosocial responses. It isshown in the second column of Box 1–1.19 Asyou perform a nursing activity, write down pa-tient’s responses. For example, you said that youwould monitor the patient’s temperature in Step4 under the nursing diagnosis Infection. InStep 5, you record those temperatures acrossfrom the intervention. Step 5 also involves writ-ing your clinical impressions and inferences re-garding the patient’s progress toward expectedoutcomes and the effectiveness of your inter-ventions to bring these outcomes about. This isa summary statement written for each nursingdiagnosis, found at the end of each interven-tion and response list. Step 5 on evaluation ofoutcomes will be expanded on in Chapters 5and 6.

DURING CLINICAL CARE: KEEP IT IN YOUR POCKET

Throughout the clinical day, you and your clini-cal faculty will have an ongoing discussion re-garding changes in patient assessment data,effectiveness of interventions, and patient re-sponses to those interventions. Keep the mapand list of interventions in your pocket; this way,everything that must be done and evaluated islisted succinctly and kept within easy reach. Asthe plan is revised throughout the day, take noteson the map, add or delete nursing interventions,and write patient responses as you go along. Asyour clinical faculty makes rounds and checks inon you and your patients, the faculty can also re-fer to the maps and intervention lists you havedeveloped as the basis for guiding your patientcare.

DOCUMENTATION

The maps, interventions, and patient responseswill become the basis of your documentation.



You will be using the revised plans and outcomeevaluations as guides to make sure you have adequately documented patient problems, in-terventions, and the evaluation of patient responses. Documentation involves correctlyidentifying patient assessment data to recordabout a problem, determining what to recordabout the interventions to correct the problem,and describing the patient’s responses to the in-terventions. Assessment, interventions, and re-sponses are all present in the concept map careplan. Concept map care plans as the basis of doc-umentation will be described in more detail inChapter 7.

MEDICATION ADMINISTRATION

Your concept map care plan will also be useful asyou prepare to administer medications. By orga-nizing the drugs to be administered under thecorrect problem, you demonstrate your knowl-edge of the relationship of the drug to the prob-lem. You can also see the interactive effects of thedrug related to the total clinical picture. For ex-ample, as you discuss Lanoxin (digitalis) admin-istration under Decreased Cardiac Output,you and your clinical faculty can also see that thepatient’s potassium level was low. What is the re-lationship between low levels of potassium andLanoxin administration? The answer is an in-creased risk of a toxic reaction by the patient todigitalis. Be prepared for your clinical faculty toask you for the current value of potassium fromthe morning blood draw. Low potassium levelshave to be corrected; in the meantime, you canbe assessing the patient carefully for adverse re-actions to the drug. You can more easily integratemedications with laboratory values and pathol-ogy if the information is all neatly categorizedunder decreased cardiac output.

In addition, you should also write downscheduled times of medication administrationnext to the drugs. You may also highlight drugson the map. Writing down administration timesand highlighting drugs helps to organize, and remind you of the importance of, the medica-tion administration times. It also decreases thechance of medication errors.

NURSING STANDARDS OF CARE

Concept map care plans are individualized plansof care built on critical analysis of patient assess-ment data, identification of medical and nursingdiagnoses, determination of nursing actions tobe implemented, and evaluation of patient responses. Development, implementation, andevaluation of safe and effective nursing care arecontingent upon nurses knowing and followingaccepted standards of care. As you plan care for apatient, a primary question you must address isthis: What are the standards of care pertinent tomy patient and specific to the applicable medicaland nursing diagnoses? Nursing students oftenwonder: “Have I included everything necessaryin this care plan?” “Am I doing everything Ishould be doing?” “Am I missing something?”Following standards of care ensures that you aredoing everything possible to provide appropriatecare to the patient. These standards may stemfrom several organizing agencies or principles.

Standards of the American Nurses Association

By law, nurses must follow guidelines for the safeand effective practice of nursing. These legalguidelines are called standards of care. The ANAhas developed general standards of nursing prac-tice, shown in Box 1–2.20 Concept map care plansare in compliance with these general standards ofcare.

Standards of the JointCommission on Accreditation of Healthcare Organizations

In addition, there are also very specific standardsto be followed when caring for patients with spe-cific problems. The Joint Commission on Accred-itation of Healthcare Organizations (JCAHO)requires that all accredited agencies have writtenpolicies and procedures for nursing care. Youmust follow these specific policies and proce-dures for any nursing care you administer. Repre-sentatives of JCAHO travel the country andreview these policies and procedures. If they arenot current, JCAHO requires that they be up-



dated if the agency desires to maintain its certifi-cation.

Fortunately for you as a student, fundamentalsand medical-surgical textbooks provide generaldescriptions of procedures similar to what is re-quired by your clinical agency. Your clinical fac-ulty will inform you of any specific requirementsof the clinical agency in which you are placed, ei-ther by explaining those requirements verbally orreferring you to the agency’s procedure manual.

Standardized Nursing Care Plans

Many organizations have developed standard-ized nursing care plans for specific medical diag-noses. These standardized nursing care plans arebased on typical nursing diagnoses of patientswith particular medical problems. Many facilitieshave general nursing care plans for nursing careof patients that are commonly seen at the site.For example, an orthopedic unit probably has astandardized care plan for the patient with a frac-tured hip, and the urology unit probably has astandardized care plan for the patient undergo-ing a transurethral resection of the prostategland. In addition, hundreds of standardized careplans have been written and published, andmany have been computerized for easy accessi-bility.

Therefore, while you are gathering data from apatient’s records to prepare your concept mapcare plan, you also need to find out whether theagency has any standardized care plans availablefor you to use. If these plans are not available onthe unit to which you are assigned, you can usepublished standardized care plan books to makesure you have not missed any important aspectsof care.

Patient Education Standards

All patients have the right to know what is wrongwith them and how to manage their own care.That makes patient education a key role fornurses. Most agencies have patient educationmaterials available that are specific to varioustypes of problems. You also need to collect thesematerials when you collect information from pa-tient records. As with standardized care plans,there are also published standardized teachingmaterials, such as booklets and movies, that maybe available for you and the patient as references.Teaching materials are usually geared toward afifth-grade reading level. Materials given to pa-tients must be carefully screened for content thatis appropriate for the patient’s individual needsand ability to comprehend the materials. De-tailed information about integrating teaching


Box 1–2 A M E R I C A N N U R S E S A S S O C I A T I O N S T A N D A R D S O F C L I N I C A LN U R S I N G P R A C T I C E

1. The collection of data about the health status of the patient is systematic and continuous. The data are ac-cessible, communicated and recorded.

2. Nursing diagnoses are derived from health status data, validated and documented.

3. The nurse identifies expected outcomes derived from the nursing diagnoses.

4. The nurse develops a plan of nursing care including priorities and the prescribed nursing approaches ormeasures to achieve the outcomes derived from the nursing diagnoses. Nursing interventions provide forpatient participation in health promotion, maintenance, and restoration.

5. The nurse implements and documents interventions consistent with the plan of care.

6. The patient and the nurse determine the patient’s progress or lack of progress toward outcome achieve-ment and documents accordingly. The patient’s progress or lack of progress toward goal achievement di-rects reassessment, reordering of priorities, new goal setting and revision of the plan of nursing care.

SOURCE: Standards of Clinical Nursing Practice, ed 2. American Nurses Publishing, American NursesFoundation/American Nurses Association, Washington, D.C., 1998, with permission.


materials with concept map care plans appears inlater chapters.

Insurance Agency andGovernment Care Standards

The high cost of health care has led to a con-certed effort by the government (which pays forMedicare and Medicaid) and health-care insur-ance companies to control costs. At the sametime that costs are being controlled, the qualityof health care is supposed to be ensured throughcareful management by health-care providers.The government and insurance companies havedeveloped specific criteria for which services willand will not be reimbursed, depending on diag-noses. All medications, treatments, surgeries, and rehabilitation programs (literally everythingdone by health-care providers) has to be pro-vided and documented according to governmentand insurance company criteria for care, or thebills will not be paid. When bills are not paid bythe government or insurance companies, health-care providers may never receive payment forservices provided. In some cases, patients may beleft with the bill. In that case, patients may de-cide to go without needed health-care servicesbecause they cannot afford them.

Insurance companies and the government paypredetermined amounts of money to agencies orphysicians providing care to patients. For exam-ple, if a patient had knee replacement surgery,the providers will receive a fixed amount ofmoney for that service. Case managers, typicallyadvanced practice nurses, are hired by insurancecompanies and health-care agencies to evaluatethe types of care given to inpatients and outpa-tients, to monitor patient progress, and coordi-nate the care of patients to guide their recoverywhile minimizing costs. These case managers arealso known as resource managers, because theycoordinate all services available to the patient.They must be aware of all resources available sothey can make the appropriate linkages betweenpatients and the appropriate services.

Teams of health-care providers includingphysicians, nurses, pharmacists, dietitians, phys-ical therapists, and social workers have devel-oped standards that guide the treatment ofpatients. Instead of separate plans of care from

the physician, dietitian, and others, the trend isfor health-care providers to collaborate and de-velop one unified plan of care. This multidis-ciplinary plan is commonly called a clinicalpathway or a critical pathway. There is careful se-quencing of clinical interventions over a specificperiod of time that all involved in the care of thepatient agree to follow. Clinical pathways outlineassessments, treatments, procedures, diet, activi-ties, patient education, and discharge planningactivities. Although clinical pathways are becom-ing a popular method of collaborative care plan-ning, they are unfortunately not available forevery diagnosis. Clinical pathways also varyslightly among clinical agencies.

As you prepare for a clinical care assignment, itis important that you know about the clinicalpathway your patient is supposed to be followingbased on the patient’s health condition. Sincenurses often spend more time with patients thanother health-care providers, nurses’ clinical rolesinclude communicating between caregivers tomake sure that the patient is making steadyprogress in the expected direction toward healthgoals enumerated on the clinical pathway. Thenursing care plan and assessment is focused onidentifying complications and quickly interven-ing to get the patient back on the clinical path-way to resume rapid progress toward health goals.

Currently, a battle is raging between health-care providers and those who pay the bills forservices, namely the government (for Medicareand Medicaid) and the insurance companies. Atone time, physicians ordered whichever teststhey felt necessary to diagnose problems andwhichever treatments they deemed necessary tofix those problems. If a physician felt that a pa-tient would benefit from an extra day in the hos-pital, the patient stayed in the hospital. If thephysician ordered certain medications to treatthe patient’s problem, the patient received them.Now, physicians have been forced to use criteriaestablished by insurance companies and the gov-ernment for diagnosing, treating, admitting, anddischarging patients—or the bill is not paid. Inessence, the view of the insurance company andgovernment is that physicians are free to treatpatients as they deem necessary. However, ifphysicians deviate from the established stan-dards and criteria for treatment, they are not



paid. You may recall that, a few years ago, thestandard used by those paying the bills was thatpatients were required to leave the hospital 24hours after vaginal childbirth. The outcry fromthe public and from health-care providers grewso loud that the length of stay for vaginal deliv-ery has now increased to 48 hours. But 20 yearsago, a woman stayed in the hospital for 4 or 5days after such a delivery.

Although this is a simple explanation of thecurrent state of affairs regarding payment for ser-vices and maintaining quality of care, it is a verycomplex problem. The complexity exists becausethe government and insurance agencies differ intypes of payment plans and criteria that form thestandards of care. In addition, the criteria are un-der constant revision.

Utilization Review Standards

Documentation of detailed assessments, accu-racy of diagnoses, and appropriateness of treat-ments and follow-up are constantly beingreviewed in all health-care settings (such as pri-vate physicians’ offices, outpatient facilities, orhospitals). Everything and everyone is under theutilization review, which is the process of evalu-ating care given by nurses and physicians and allother health-care providers and agencies. Nursesprimarily manage the utilization reviews, armedwith specific criteria for auditing individualhealth-care providers and the delivery of servicesin each health-care setting. These nurses arehired by health-care agencies and by insurancecompanies. Utilization reviewers do not usuallyhave direct contact with patients; they only re-

view charts. They judge the necessity and appro-priateness of care and the efficiency with whichcare is delivered.

MANAGED CARE IN HOSPITAL SETTINGS

There is a direct relationship between the carestandards described above and the management ofcare. Currently, nearly all patients who enter hos-pitals find themselves in managed care deliverysystems. Typically, patients entering health-care facilities have nurse case managers assigned tomonitor and coordinate their progress through thehealth-care system. These case managers are expe-rienced nurses, with most holding advanced degrees or specialty certifications. These nursescarefully manage hospital resources and coordi-nate discharge planning. With strict criteria im-posed by government and insurance agencies toensure rapid discharge from acute-care facilities, allnurses must carefully document and justify com-plications and additional problems with patientsto ensure that quality care is rendered and finan-cial obligations are met (that is, the bills are paidby government and insurance agencies). Thesenurses monitor patient progress, and especiallytrack high-risk patients, as well as all patients withcomplications. These hospital-based nurse casemanagers interact with service providers and withinsurance providers; thus, they are considered re-source managers. It is essential to make links forpatients to home health services, transitional careunits, long-term care facilities, and other agenciesto provide quality care.


C H A P T E R S U M M A R Y

The purpose of concept map care planning is to assist with critical thinking,analysis of clinical data, and planning comprehensive nursing care for your pa-tients. A concept map is based on theories of learning and educational psychol-ogy, and is a diagrammatic teaching/learning strategy that provides you with theopportunity to visualize interrelationships between medical and nursing diag-noses, assessment data, and treatments. These visual maps and interventions arepersonal pocket guides to patient care, and they form the basis for discussion ofnursing care between you and your clinical faculty.

Before developing a concept map, you must perform a comprehensive patientassessment. Then, in Step 1 of concept mapping, you develop a skeleton diagram



of health problems. In Step 2, you analyze and categorize specific patient assess-ment data. In Step 3, you indicate relationships between nursing and medical di-agnoses. In Step 4, you develop patient goals, outcomes, and nursing interventionsfor each nursing diagnosis. And in Step 5, you evaluate the patient’s response toeach specific nursing intervention and summarize your clinical impressions.

The development of concept map care planning is based on understanding andintegrating accepted standards of patient care. Standards of care are derived fromthe standards of the ANA, the JCAHO, standard nursing care plans, standards ofpatient teaching, clinical pathways, insurance agency and government paymentstandards, and utilization review standards. As a result of these standards, hospi-tals have become centers for managed care and are employing nursing case man-agers as patient care resource coordinators. All parties involved with health-caredelivery, including health-care agencies, health-care providers, insurance compa-nies, and the government are finding ways to decrease costs while attempting tomaintain quality services through managed care.

L E A R N I N G A C T I V I T I E S

1. Identify the names and locations of books and computer software that containstandardized nursing care plans that you can use as standards for patient care.

2. Locate samples of standards of care at your assigned clinical agency. Bring toclass for discussion a standard nursing care plan from a local agency, a clinicalpathway, a standardized specific procedure, and patient education materials.

3. Locate the procedure manual from a local health-care agency and compare aprocedure you are currently learning from your procedures text to the sameprocedure in the agency’s manual.

4. Identify the person or people at your agency who perform case management,discharge planning, and utilization review. Invite one of them to a clinicalpostconference to describe their role in decreasing costs while maintainingquality of care in the managed care environment.

R E F E R E N C E S

1. Novak, J, and Gowin, DB: Learning How to Learn.Cambridge University Press, New York, 1984.

2. Ausubel, DP, Novak, JD, and Hanesian, H: Educa-tional Psychology: A Cognitive View, ed 2. Werbeland Peck, New York, 1986.

3. Worrell, P: Metacognition: Implications for in-struction in nursing education. J Nurs Educ29(4):170, 1990.

4. All, AC, and Havens, RL: Cognitive/concept map:A teaching strategy for nursing. J Adv Nurs25:1210, 1997.

5. Baugh, NG, and Mellott, KG: Clinical conceptmaps as preparation for student nurses’ clinical ex-periences. J Nurs Educ 37(6):253, 1998.

6. Daley, BJ, et al: Concept maps: A strategy to teachand evaluate critical thinking. J Nurs Educ38(1):42, 1999.

7. Daley, B: Concept maps: Linking nursing theory toclinical nursing practice. Journal of ContinuingEducation in Nursing 27(1):17, 1996.

8. Irvine, L: Can concept maps be used to promotemeaningful learning in nurse education? J AdvNurs 21:1175, 1995.

9. Kathol, DD, et al: Clinical correlation map: A toolfor linking theory and practice. Nurse Educator.23(4):31, 1998.

10. Novak, J, and Gowin, DB: Op cit.11. Ausubel, DP, et al: Op cit.12. American Philosophical Association. Critical think-

ing: A statement of expert consensus for purposes


of educational assessment and instruction. Centeron Education and Training for Employment, Col-lege of Education, The Ohio State University.(ERIC Document Reproduction No. ED 315-423)Columbus, Ohio, 1990.

13. Schuster, PM: Concept maps: Reducing clinicalcare plan paperwork and increasing learning.Nurse Educator. 25(2):76, 2000.

14. Nursing’s social policy statement. AmericanNurses Association, Washington, D.C., 1995.

15. Standards of Clinical Nursing Practice, ed 2. Amer-ican Nurses Publishing, American Nurses Founda-tion/American Nurses Association, Washington,D.C., 1998.

16. Schuster, PM: Op cit.17. Ibid.18. Ibid.19. Ibid.20. Standards of Clinical Nursing Practice, ed 2.,

Op cit.



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