Care Plan/Concept Map 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 
Nursing Process: Systematic method of

giving humanistic care that focuses on achieving outcomes in a cost effective manner.

Nursing Care Plans 
Written guidelines for client care  Organized so nurse can quickly identify

nursing actions to be delivered  Coordinates resources for care  Enhances the continuity of care  Organizes information for change of shift report

The Nursing Process is a Systematic Five Step Process 
Assessment  Diagnosis  Planning  Implementation  Evaluation

TJC)  Basis for NCLEX exams  Based on principles and rules that promote critical thinking in nursing .Why Use the Nursing Process for Care Plans  Requirement set forth by national practice standards (ANA.

 Entire plan is based on the data you collect. .Putting it All Together  Assessment: The first step in determining a patients¶s health status.  Gather information. data needs to be complete and accurate  Collect. put pieces of the health puzzle together. verify. report and record the data. identify patterns.  Report significant abnormalities immediately. and organize data.

Jones complains his throat and mouth are dry. especially the warm water in the pitcher. . He is allowed fluids.Case Scenario  Mr. He also hates to bother the nurse. The nurse notes his oral mucosa is dry and cracked and his urine output for the last shift is low. but doesn¶t like water. but has had almost nothing to drink all evening. He tells you he would like to drink.

make sense of patterns .Assessment  irst step in determining health status  Gather information  Gather all the ³puzzle pieces´ to put together a clear picture of health status  Entire plan is based on data collected  Data needs to be complete and accurate.

5 Activities Needed to Perform a Systematic Assessment  Collect data  Verify data  Organize data  Identify Patterns  Report & Record data .


 Other information resources include: family.Comprehensive Data Collection  Begins before you actually see the patient (Nurse report from ER. relevant nursing literature. Chart reviews)  Continues with admission interview and physical assessment once you meet patient. diagnostic studies. old medical records.  Consider age. growth & development . significant others. nursing records.

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 .What·s Important Data?  Name. age.

 Standardized risk assessments: Pressure ulcers. DVT . GI. respiratory. musculoskeletal.Comprehensive Physical Assessment  Vital signs  Height & weight  Review of systems (neurological/mental status. skin and wounds. falls. GU. cardiovascular.


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 .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.


. anticipating complications. initiating actions to ensure appropriate and timely treatment.Diagnosis  Assessment Critical 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.

 Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved  NANDA list of acceptable diagnoses.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. . updated every 2 years.

skill.Diagnostic Reasoning  Apply critical thinking to problem identification  Requires knowledge. 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 .

but no true evidence (Risk for altered skin integrity) . (Fluid Volume Deficit)  Potential/Risk for Diagnosis: client¶s data base contains risk factors of diagnosis.Nursing Diagnosis  Actual or Potential problems identified  Actual: actual evidence of signs/symptoms of diagnosis exist.

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.

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 . Decreased.Writing A Nursing Diagnosis  Use accepted qualifying terms (Altered.

hospital policy and procedure manuals. based on goals. National practice guidelines. what needs to be done first.  Identify your goals & outcomes.  Apply Nursing Standards.  Determine interventions.  Record the plan (care plan/concept map) .Planning: 4 Part Process  Set your priorities of care. derive them from nursing diagnosis/problem. Nurse Practice Act. what can wait.

( state time period to achieve goal) . control or absence of problem  The patient will have no signs of skin breakdown during hospital stay.  Outcome needs to be time related.Planning  Risk for Impaired skin integrity related to immobility  Now restate the first clause in a statement that describes improvement.

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 .Short Term vs.

prognosis)  Set goals mutually with client  Goals should be measurable. use measurable.Achieving Goals/Outcomes  Be realistic in setting goals. observable verbs  Identify one behavior per outcome  When indicated use short-term vs. long tern goals . growth & development level. (look at overall health state.

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) .

combining nursing actions and physician orders. activity orders .  Physician orders: pain medication.  Ineffective Airway Clearance related to incisional pain  Nursing Actions: Ascultate breath sounds every four hours. Assist with coughing and deep breathing every hour etc.Determining Interventions  Interventions will be collaborative.

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  Action taken by nurse .

monitoring guidelines.Types of Nursing Interventions  Protocols: Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation  Standing Orders: Document containing orders for the conduct of routine therapies. and/or diagnostic procedure for specific condition .

personnel. environment) .Implementation Process involves:  Reassessing the client  Reviewing and revising the existing care plan  Organizing resources and care delivery (equipment.

Evaluation  Evaluation of individual plan of care includes determining outcome achievement  Identify variables/factors affecting outcome achievement  Decide where to continue/modify/terminate plan  Continue/modify/terminate plan based on whether outcome has been met (partially or completely)  Ongoing assessment of QI .

Evaluation  Step of the nursing process that measures the client¶s response to nursing actions and the client¶s progress toward achieving goals  Data collected on an on-going basis  Supports the basis of the usefulness and effectiveness of nursing practice  Involves measurement of Quality of Care .

adjustments of the care plan are made  If the goal was met.Evaluation of Goal Achievement  Measures and Sources: Assessment skills and techniques  As goals are evaluated. that part of the care plan is discontinued  Redefines priorities .

Concept Map Care Plans  Innovative approach to planning & organizing nursing care.  Essentially a diagram of patient problems and interventions  Ideas about patient problems and interventions are the ³concepts´ to be diagrammed. analyze relationships.  Enhances critical thinking and clinical reasoning  Used to organize patient data. establish priorities .

Theoretical Basis of Concept Maps  Roots in education and psychology  Also known as mind maps. cognitive maps  Concept mapping requires critical thinking  New knowledge is built on preexisting knowledge. new concepts are integrated by identifying relationships .

Steps in Concept Map Care Planning  Develop a Basic Skeleton Diagram  Analyze and Catagorize Data  Analyze Nursing Diagnoses Relationships  Identifying Goals. Outcomes. & Interventions  Evaluate patient responses .

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