Concept Mapping On Clincal Case Studies For Medical Surgical Nursing.
Concept Mapping On Clincal Case Studies For Medical Surgical Nursing.
I need a concept map done for each of the following clinical case studies. I have uploaded the guidelines and a PDF file of the case studies. and I have uploaded the steps on how to complete the concept maps. Concept Mapping On Clincal Case Studies For Medical Surgical Nursing.
ClinicalReasoningCasesinNursing.pdf
Fall2020ClinicalInstructionsforAssignments.docx
ConceptMapStep1234LIU6.doc
NURSING PROCESS PAPERS: CONCEPT MAPPING
The Nursing Process: Assessment, Nursing Diagnosis, Goals, Interventions, and Evaluation.
PREPARATION: ASSESSMENT PHASE.
· Gather clinical data: assess the patient; review the patient records, laboratory data, medications, and treatments. Objective and subjective data are important.
STEP 1: DEVELOP A BASIC SKELTON DIAGRAM (See Example #1)
· Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care.
· In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis).
· Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses – actual or potential – to this reason for seeking health care (usually the medical diagnosis).
· Recognize major problem areas. (You do not have to state the nursing diagnosis yet.)
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STEP 2: ANAYZE & CATEGORIZE THE DATA (See Example #2)
· Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses.
· Data can be listed in more than one area if it is relevant to more than one category.
· If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor.
· Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map.
STEP 3: ANALYZE NURSING DIAGNOSES RELATIONSHIPS (See Example #3)
· Draw lines between nursing diagnoses to indicate relationships.
· Label the general problems you have identified according to the North American Diagnosis Association (NANDA) classification system.
STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS (See Example #4)
· On a separate piece of paper, for each nursing diagnosis write your patient goals/outcomes.
· Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …”
· List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are carefully monitoring, treatments, patient education, and medications.
· Be complete and think, “What am I doing this day for this patient/client”.
· Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day.
STEP 5: EVALUATE PATIENT’S RESPONSES (See Example #4)
· As you complete a nursing intervention, write down the patient’s responses.
· This step also involves writing your clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about. Did you meet the goal or not?
SAMPLE PATIENT for Nursing Process Paper: Concept Mapping
Your patient for today is W. C., a 76-year-old male who was admitted 4 days ago with an abdominal abscess and bowel obstruction. He went to the operating room for an Exploratory Laparotomy two days ago.
He has a history of DM Type 2, Cancer of the lung 2 years ago that was treated with radiation and chemotherapy, an enlarged prostrate, Cancer of the bone with chronic bone pain in his right leg, and Atrial Fibrillation with a pulse rate of 128 and irregular.
He has 2 abdominal drains with purulent drainage and a temp of 100.5 F. Currently he is NPO with a NG tube to suction. He has an IV of D5 RL at 100 mL/hr. He has decreased breaths sounds on the right lower lung field and is on Oxygen at 6L by mask. He has a Foley catheter in place.
He says he is nervous; clenching his fists, and says that he is afraid of dying.
Medications: PCA with Morphine, Digoxin, Kefzol, Ventolin inhaler, Proscar, and Regular Insulin by sliding scale.
STEP 1: DEVELOP A BASIC SKELETON DIAGRAM (Example #1)
· Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care.
· In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis).
· Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses to this reason for seeking health care (usually the medical diagnosis).
Recognize major problem areas. (You do not have to state the nursing diagnosis yet.)
STEP 2: ANALYZE & CATEGORIZE THE DATA (Example #2)
· Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses.
· Data can be listed in more than one area if it is relevant to more than one category.
· If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor.
· Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map.
Solid lines are definite relationships
Dotted lines are possible relationships
STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS
(Example #4)
· On a separate piece of paper, for the top three priority nursing diagnosis write your patient goals/outcomes.
· Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …”
· List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are supposed to be carefully monitoring, treatments, patient education, and medications.
· Be complete and think, “What am I doing this day for this patient/client”.
· Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day.
STEP 5: EVALUATE PATIENT’S RESPONSES (Example #4)
· As you complete a nursing intervention, write down the patient’s responses.
· This step also involves writing you clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about.
| Problem/Nursing Diagnosis #1: Impaired Gas ExchangeGoal/Outcome: The patient will maintain an oxygen saturation > 95% | |
| Nursing Interventions:1. Monitor breath sounds q4h2. Check VS, esp resp q4h3. Do CDB & IS4. Maintain O2 mask in place5. Assess O2 Sat q4h6. Monitor Hgb7. Administer Venotlin | Patient Responses:1. Decreased breath sounds R lower lung field2. 8am: 128/78, HR112. R20, 100F (orally)Noon: 130/76, HR96, R20, 98.4F (orally)3. Done q2h, non-productive and weak cough4. In place except for breakfast5. 8am 96%, noon 96%6. Not available7. 10am as ordered |
| Evaluation: Breathing nonlabored, cooperative with treatments but cough is very weak. O2 sat remains > 95% |
| Problem/Nursing Diagnosis #2: Decreased Cardiac OutputGoal/Outcome: The patient will maintain a BP and HR WNL | |
| Nursing Intervention:1. Check VS q4h, esp BP & HR2. Apical pulse check prior to Digoxin administration3. Check Potassium level4. Assess mental status5. Assess urine output6. Assess peripheral pulses | Patient Responses:1. 8am: 128/78, HR 112, R 20, 100F (orally)Noon: 130/76. HR 96, R 20, 98.4F(orally)2. 112/min at 10am3. K=3.91. A&O x 32. > 30 mL/h3. All +2 |
| Evaluation: BP remains stable, PR continues to be elevated – continue with assessments and Digoxin administration as ordered |
| Problem/Nursing Diagnosis #3: Risk for fluid volume deficitGoal/Outcome: The patient’s N/G tube and drains will remain patent, and the I&O will balanced | |
| Nursing intervention:1. Assess new lab values2. Assess I&O3. NPO4. Mouth care5. Monitor N/G tube, check drainage6. Assess FBS7. Assess bowel sounds8. Assess for distention9. Assess drainage from drains | Patient Responses:1. Electrolytes WNL (Na, K,)2. For 6 hours: Intake 600mL/ Output 650 mL3. NPO except for ice chips4. Good oral hygiene, no sordes5. Patent, draining bile colored fluid (75mL)6. 109 at 10am7. Hypoactive8. None, soft abdomen9. Purulent yellow, foul-smelling |
| Evaluation: Tubes and drains are patent, output is 50 mL > intake, and electrolytes are WNL, |
| Problem/Nursing Diagnosis #5: PainGoal/Outcome: The patient’s pain level will remain at 3 or below during this shift | |
| Nursing Interventions:1. Assess pain level2. Assess patency of PCA line3. Positioning4. Check noise, lighting5. Backrub | Patient Responses:1. Pain level 2-32. Patent line3. Positioned on side with a pillow4. Decreased light, patient fell asleep5. Stated it hurt to be touched |
| Evaluation: Morphine by PCA is controlling the pain at a 2-3 level, positioning and decreasing the lighting (non-pharmacological measures) were helpful. |
| Problem/Nursing Diagnosis #6: InfectionGoal/Outcome: Patient’s temperature will be WNL within 24 hurs | |
| Nursing Interventions:1. Monitor temp q 4h2. Assess WBC3. Bed bath4. Check skin integrity5. Foley care6. Oral care7. Assess wounds, drains8. Administer Kefzol | Patient Responses:1. T 100F at 8am, 98.4F at 12noon2. WBC 12,0003. Cooperated, but did not like being touched – it hurt4. No signs of breakdown, Decubitus Risk: 175. Patent, skin pink and intact6. Good oral hygiene, no sign of infection7. Dressing changed by physician, skin edges approximated with sutures, erythematous, dry; drain purulent yellow, foul smelling8. Given IV at 10am |
| Evaluation: Wound intact, drainage from drains is purulent, temp is WNL |
Infection
Immobility
Oxygenation
REASON FOR SEEKING HEALTH CARE:
Abdominal Abscess/
Bowel Obstruction/
Post-op 2 days
Fluid and Electrolyte Imbalance
Elimination
Anxiety
Pain
Cardiac
REASON FOR SEEKING HEALTH CARE:
Abdominal Abscess/
Bowel Obstruction/
Post-op 2 days
Priority assessment: Pain, Distention, Bowel Sounds, I&O, Drainage, Wound
Fluid Imbalance
NPO
Temp 100.5F
NG tube to suction
Abdominal drains with drainage
IV of D5RL @ 100mL/hr
Pain
Abdominal abscess, surgical wound
Ca of bone/lung
PCA with Morphine
Cardiac
Atrial Fibrillation
Rate – 128 & irregular
Digoxin
Infection
Abscess – wound
Two drains, purulent drainage
Temp – 100.5F
Kefzol
Anxiety
Surgery – post-op
Verbalizes that he is nervous and afraid of dying
Elimination
Foley
Enlarged Prostate
Proscar
Breathing/Oxygenation
Ca of lung (history)
Radiation/chemotherapy (history)
Decreased breath sounds, right lower lung
Oxygen @ 6L by face mask
Mobility
Ca of bone (history)
Fall Protocol
Tubes (tripping)
Concept Map Directions 1