concept mapping... for the slightly confused

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Concept Mapping ...for the slightly confused Diana Benton RN - 2010

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Page 1: Concept Mapping... for the slightly confused

Concept Mapping...for the slightly confused

Diana Benton RN - 2010

Page 2: Concept Mapping... for the slightly confused

...focused on a holistic nursing view of the patient, rather than a disease model

What’s a concept map anyway?

...an innovative approach to planning and organizing nursing care

Page 3: Concept Mapping... for the slightly confused

...guides the student’s focus so he or she can learn to analyze relationships in clinical data and to prioritize the

needs of a specific client

...helps with organizing the problems and care of patients in a logical

fashion

For the student

Page 4: Concept Mapping... for the slightly confused

... a visual representation of the critical thinking ability of inexperienced nurses

For the instructor

Page 5: Concept Mapping... for the slightly confused

A description we’ll expand upon is...

Page 6: Concept Mapping... for the slightly confused

5. evaluation

1. assessment2. nursing diagnosis3. goal4. intervention

A concept map isa diagram

of the sequential steps of the nursing process.

Page 7: Concept Mapping... for the slightly confused

Let’s get started...

This is D.J. - he fractured his right femur when he jumped off the roof. You’d think a 42 year old

guy woulda known better!

Page 8: Concept Mapping... for the slightly confused

Although there are many different ways to make a concept

maplet’s do it my way and...

...start with a circle in the center of the paper identifying the patient.

D.J.42 year old

male

Admitting dx: Fx Right

Femur

Page 9: Concept Mapping... for the slightly confused

Then, to plan the patient’s care, you’ll utilize...

the nursing process

Page 10: Concept Mapping... for the slightly confused

ssess the

patient

and gather subjective and objective data

To begin....

Page 11: Concept Mapping... for the slightly confused

Subjective Assessment

Data(information that only the client

feels and can describe)

MY LEG HURTS !

When I sit up

I get dizzy

headed.

I feel awful.

I’m depressed.

I feel lik

e I’m

gonna throw up.

Sympto

ms

Page 12: Concept Mapping... for the slightly confused

Objective Assessment

Data (observable or

measurable facts)Vital Signs

BP 150/68 - Pulse 96

Weight200#

Moaning

Pallor

SignsConcurrent Health Problems

Pertinent Labsand

Diagnostic Tests

Buck’s t

raction (R

) leg

Xray: (R) femoral neck fracture

Make 2 more circles.It will help you remember to check D.J.’s chart for additional objective data and besides, you could use the extra space!

Page 13: Concept Mapping... for the slightly confused

Let’s see how this assessment data looks when added to

your concept map

Page 14: Concept Mapping... for the slightly confused

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Objective Assessment Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

ProblemsNone

Needs Further Assessment

c/oPain (R)

leg

BP = 150/68

Pulse = 98Xray:

(R) femoral neck fracture

If you realize you need to get more information .. make a note

here to remind yourself

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Page 15: Concept Mapping... for the slightly confused

iagnosis

ursing

Now to come up with a...

Page 16: Concept Mapping... for the slightly confused

Look at the assessment data.

Identify patterns of related responses to an actual or potential health problem.

Xray: (R) femoral

neck fracture

BP = 150/68

Pulse = 98Moaning

c/oPain (R) leg

Page 17: Concept Mapping... for the slightly confused

Based on the problem identified, chose an appropriate nursing

diagnosis from the NANDA list.

ACUTE

PAIN

Page 18: Concept Mapping... for the slightly confused

D.J.42 year old

male

Admitting dx: Fx Right

Femur

Subjective Assessment Data

Objective Assessment

Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

Problems

None

Needs Further Assessmentc/o

Pain (R) leg

BP = 150/68

Pulse = 98Xray:

(R) femoral neck fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAIN

Add this nursing diagnosis to your concept map.

You must be able to show the relationship between each nursing diagnosis you chose and the assessment data upon which it was based.

Page 19: Concept Mapping... for the slightly confused

As you add more diagnoses...

... your map can begin to look like a confusing mess.

Skip the lines.

ACUTE PAIN

Another Diagnosis

Another Diagnosis

Page 20: Concept Mapping... for the slightly confused

Instead... use a 3 part nursing diagnosis that includes:

Nursing Diagnosis: ACUTE PAIN

R/T (R) femoral neck fracture

Diagnosis

Cause“related to”

Indicators“as evidenced

by”

AEB c/o Pain (R) leg / moaning / BP = 150/68 / pulse 98

Page 21: Concept Mapping... for the slightly confused

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Objective Assessment

Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

Problems

None

Needs Further Assessmentc/o

Pain (R) leg

BP = 150/68

Pulse = 98Xray:

(R) femoral neck fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

You gotta admit...that

looks a lot better!

When added to your concept map it should look like this:

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fracture

AEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

Page 22: Concept Mapping... for the slightly confused

After you have decided on a nursing diagnosis, set a patient-focused...

oal

specific measurable

attainable

so you will be able to determine if desired outcomes of care are achieved

realistic timely

Page 23: Concept Mapping... for the slightly confused

ACUTE PAIN

So what’s gonna be your patient-focused goal

The will...

he just broke his leg...it’s gonna hurt!

...have no pain

...report pain controlled at a tolerable level this is more realistic but...

Page 24: Concept Mapping... for the slightly confused

How are you gonna determine if the pain is tolerable

“reports pain levels of < 5 on a scale of 0 to 10

within the next 24 hours”

specific

measurable

attainable realistic timely

Now that’s a smart goal

Page 25: Concept Mapping... for the slightly confused

D.J.42 year old

male

Admitting dx: Fx Right

Femur

Subjective Assessment Data

Objective Assessment

Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

Problems

None

Needs Further Assessmentc/o

Pain (R) leg

BP = 150/68

Pulse = 98Xray:

(R) femoral neck fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

Put this goal on your concept map.

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours

Page 26: Concept Mapping... for the slightly confused

Now you need to decide on nursing...

nterventions

that, when implemented, will enable the patient to achieve the stated goal

Page 27: Concept Mapping... for the slightly confused

Explain 0 to 10 pain scale / need not wait until pain is severe

Maintain Buck’s traction to muscle spasms

Provide periods of uninterrupted rest

Refresh ice to right femur prn

Administer ordered pain meds prn / assess pain relief 30 min. after medicating

I know some!

Page 28: Concept Mapping... for the slightly confused

D.J.42 year old

male

Admitting dx: Fx Right

Femur

Subjective Assessment Data

Objective Assessment

Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

Problems

None

Needs Further Assessmentc/o

Pain (R) leg

BP = 150/68

Pulse = 98 Xray: (R) femoral

neck fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Add your interventions.

Interventions:

Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Buck’s traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours

Page 29: Concept Mapping... for the slightly confused

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Pertinent Labs and Diagnostic Tests

Concurrent Health Problems

None

Needs Further Assessment

c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral neck

fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Following the same sequence of steps, you can develop additional nursing diagnoses along with goals and interventions.

Objective Assessment Data

Nursing Diagnosis:

Interventions:

Goal:

Nursing Diagnosis:

Goal:

Interventions:

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Interventions:

Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Buck’s traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Page 30: Concept Mapping... for the slightly confused

At this point...

prioritize the needs of your patient based on

Maslow’s Hierarchy of Needs.

Page 31: Concept Mapping... for the slightly confused

Maslow’s Hierarchy of Needs

Self-actualization

Esteemfeeling of accomplishment

Love and belongingintimate relationships and acceptance

Safetyfeel safe and avoid danger

Physiological needs basic to human survival oxygen, water, food, shelter, and sleep

Page 32: Concept Mapping... for the slightly confused

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Pertinent Labs and Diagnostic Tests

Concurrent Health Problems

None

Needs Further Assessment

c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral neck

fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAINNumber each nursing

diagnosis on your concept map in order of priority.

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Objective Assessment Data

Nursing Diagnosis:

Interventions:

Goal:

Nursing Diagnosis:

Goal:

Interventions:

1

2

3

Interventions:

Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Buck’s traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Page 33: Concept Mapping... for the slightly confused

valuation

Lastly, do an...

of the effectiveness of the interventions in relation to goal set

if goal is not being met, what changes do you need to make?

Page 34: Concept Mapping... for the slightly confused

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Objective Assessment

Data

Pertinent Labs and Diagnostic Tests

Concurrent Health

Problems

None

Needs Further Assessment

c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral

neck fracture

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Interventions:

Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Buck’s traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Evaluation:Goal met – patient reports pain controlled between levels 1 - 4 during past 24 hours

1

Page 35: Concept Mapping... for the slightly confused

Yea, you just made a...

... concept map!Wasn’t that easy?

Page 36: Concept Mapping... for the slightly confused

Client

Subjective Assessment Data

Objective Assessment Data

Needs Further Assessment

Pertinent Labs and Diagnostic Tests

Nursing Diagnosis: ___________________________________ Goals: ___________________________________ Interventions:

Evaluation

Nursing Diagnosis: ____________________________________ Goals: ____________________________________ Interventions:

Evaluation

Nursing Diagnosis: _____________________________________ Goals: _____________________________________ Interventions

Evaluation

Concurrent Health Problems

CONCEPT MAP