Please if anyone can help, I have to do a care map and we have only done a couple in class and I have a hard time getting started. My pt. is 94, her medical diagnosis is renal insufficiency & hyponatremia her labs show a UA w/ small blood, leuk.-trace, RBC-3-5, bact. few, her EKG showed AFIB, chest x-ray- mild component of CHF, her B/P-97/61 w/hypertensive meds shes also on lasix. please any help or guidance would be helpful!!
Dec 16, '07
there is all kinds of information on care mapping on this sticky thread:
a care map is just a different physical way of presenting a care plan. as with any care plan you follow the steps of the nursing process. step #1 was to do your assessment of the patient. in step #2 you separate out the abnormal data to determine what your patient's problems are. those problems can then have nursing diagnostic labels attached to them. the abnormal data that you listed was:
- rbcs in her urine
- trace leukocytes in urine
- bacteria in her urine
- atrial fibrillation on the ekg
- b/p of 97/61
however, i'm sure there were more symptoms that you didn't list, especially with a potential medical diagnosis of chf. now, from this list you look for nursing diagnoses that have one or more of those symptoms (defining characteristics). then, in step #3 your goals and nursing interventions are determined and based upon those symptoms. what is different about care maps is that all this information is placed into a care map form rather than a list or chart.