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Care Plan/Concept Map Workshop
Care Plan/Concept Map Workshop
Workshop
Nursing Care Plans/Concept Maps
Utilize the Nursing Process to construct
an individualized plan of care for a
patient based on a critical analysis of
patient assessment data
Collect data
Verify data
Organize data
Identify Patterns
Report & Record data
Comprehensive Data Collection
Begins before you actually see the patient
(Nurse report from ER, Chart reviews)
Continues with admission interview and
physical assessment once you meet patient.
Other information resources include: family,
significant others, nursing records, old
medical records, diagnostic studies, relevant
nursing literature.
Consider age, growth & development
What’s Important Data?
Name, age, gender, admitting diagnosis
Medical/surgical history, chronic illnesses
Advanced Directives
Laboratory Data/Diagnostic tests
Medications
Allergies
Support Services
Psychosocial/Cultural Assessment
Emotional state
Comprehensive Physical Assessment
Comprehensive Physical Assessment
Vital signs
Height & weight
Review of systems (neurological/mental
status, musculoskeletal, cardiovascular,
respiratory, GI, GU, skin and wounds.
Standardized risk assessments:
Pressure ulcers, falls, DVT
Organizing Assessment Data
Cluster data into groups according to a
nursing or medical model (Maslow’s Basic
Human Needs Model)
Clustering data helps maintain a nursing
focus, allows patterns to be recognized
Cluster by body system or need deficit
Helps to identify nursing diagnosis pertinent
to your client
Example: All information gathered regarding
nutritional status may help to identify
nutritional alterations
Diagnosis
AssessmentCritical analysis of data
Diagnosis or Problem Identification
Laws & standards continue to change to
reflect how nursing practice is growing
(APN role)
Novice nurse responsible for
recognizing health problems,
anticipating complications, initiating
actions to ensure appropriate and timely
treatment.
Identifying Nursing Diagnosis
Common language for nurses
A clinical judgment about an individual, family
or community response to an actual or
potential health problem or life process,
Nursing diagnosis provide a basis for
selection of nursing interventions so that
goals and outcomes can be achieved
NANDA list of acceptable diagnoses, updated
every 2 years.
Diagnostic Reasoning
Apply critical thinking to problem
identification
Requires knowledge, skill, and
experience
Big Picture
Fundamental Principles of Diagnostic
Reasoning
Recognize diagnoses
Keep an open mind
Back up diagnosis with evidence
Intuition is a valuable tool for problem
identification
Independent thinker
Know your qualifications & limitations
Nursing Diagnosis
Actual or Potential problems identified
Actual: actual evidence of
signs/symptoms of diagnosis exist.
(Fluid Volume Deficit)
Potential/Risk for Diagnosis: client’s
data base contains risk factors of
diagnosis, but no true evidence (Risk for
altered skin integrity)
Writing a Nursing Diagnosis
Actual Problems: Problem (NANDA
label) & Etiology & Supporting Signs
and Symptoms
Impaired Communication related to
language barrier as evidenced by
inability to speak English
Writing a Nursing Diagnosis
Potential or Risk Problems: Problem
(NANDA label) & etiology or problem &
risk factors with related to statement
linking problem to risk factors.
Risk for Impaired skin integrity related to
obesity, excessive diaphoresis, and
immobility.
Writing A Nursing Diagnosis
Use accepted qualifying terms (Altered,
Decreased, Increased, Impaired)
Don’t use Medical Diagnosis (Altered
Nutritional Status related to Cancer)
Don’t state 2 separate problems in one
diagnosis
Refer to NANDA list in a nursing text
books
Planning: 4 Part Process
Set your priorities of care, what needs to be
done first, what can wait.
Apply Nursing Standards, Nurse Practice Act,
National practice guidelines, hospital policy
and procedure manuals.
Identify your goals & outcomes, derive them
from nursing diagnosis/problem.
Determine interventions, based on goals.
Record the plan (care plan/concept map)
Planning
Risk for Impaired skin integrity related to
immobility
Now restate the first clause in a statement
that describes improvement, control or
absence of problem
The patient will have no signs of skin
breakdown during hospital stay.
Outcome needs to be time related. ( state
time period to achieve goal)
Short Term vs. Long Term Goals
Short term goal can be achieved in a
reasonable amount of time ( few hours to few
days)
Long term goals may take weeks/months to
be achieved
Client will ambulate down the hall within 2
days.
Client will walk the length of the hallway
independently by the end of 2 weeks
Achieving Goals/Outcomes
Be realistic in setting goals. (look at overall
health state, growth & development level,
prognosis)
Set goals mutually with client
Goals should be measurable, use
measurable, observable verbs
Identify one behavior per outcome
When indicated use short-term vs. long tern
goals
Determining Interventions
Nursing interventions are actions performed
by nurse to reach goal or outcome
Monitor health status
Minimize client risks
Direct Care Intervention: Direct action
performed to client (inserting foley catheter)
Indirect Care Intervention: actions performed
away from client ( looking at lab results)
Determining Interventions
Interventions will be collaborative,
combining nursing actions and
physician orders.
Ineffective Airway Clearance related to
incisional pain
Nursing Actions: Ascultate breath
sounds every four hours, Assist with
coughing and deep breathing every
hour etc.
Physician orders: pain medication,
Implementation
Putting your plan into action
Set priorities after report
Assess and reassess
Perform interventions
Chart client responses
Give report to next shift
Implementation of Nursing
Interventions
Describes a category of nursing
behaviors in which the actions
necessary for achieving the goals and
outcomes are initiated and completed