Can someone help me with concept mapping please?

Published

Hi, I'm trying to work on my concept map & I'm just not sure if I'm doing it correctly or not...Our program gave us like a 5 minute lecture on these maps & everyone seems to be lost on it....Anyways here goes....

My diagnosis was: Hyponatremia

Reason for needing healthcare: Falls

Here's some key problems NANDA Diagnoses & supporting data I have so far:

- Altered thought processes r/t neurological dysfunction

1.) Progressive dementia

2.) 65+

3.) Progressive dementia

4.) Reminding patient to watch fluid intake

5.) CT Head results

- Risk for falls r/t diminished mental status

1.) 65+

2.) Patient requires use of assistive devices

3.) History of falls

4.) CT head results

5.) PT results; staggering right leg possibly r/t CT results.

- Fluid volume excess r/t increase in ADH & H2O retention

1.) Low serum Na

2.) SIADH

3.) Water intoxication, no signs of edema, pt on

4.) Patient complaining of headache & nausea.

- Excess fluid volume r/t excessive intake of hypotonic fluids

1.) Patients poor appetite but drinks a lot of fluids.

2.) I wanna say intake > output; however, my patient's output was higher than their intake but they did have a high PVR earlier in the day like of 300 mL.

I'm connecting a lot of these boxes together with one another & just see 3 more key problems. But just curious, does that look like I'm doing this right?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Ok is this a real patient? or did they just give you a diagnosis?

Up Vote Up Vote ×

Sorry, I should've said that. It was a real patient, were making a real copy of our concept map now.

Up Vote Up Vote ×

Thank you, that does help. Our instructor wants us to put actually nursing diagnoses though instead of breaking it up by like pain, immobility, etc. While some instructors are letting other clinical groups do that, kind of a double standard I think. But I guess, does it seem like I"m at least writing my nursing diagnoses correctly?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Care maps are the nursing process. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

 

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

  1. Assessment
    (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/nursing diagnosis
    (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning 
    (write measurable goals/outcomes and nursing interventions) 
  4. Implementation 
    (initiate the care plan)
  5. Evaluation 
    (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Sorry, I should've said that. It was a real patient, were making a real copy of our concept map now.
I can't help you yet. I need the assessment of your patient
Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Does she have progressive dementia by diagnosis? Is her confusion possibly due to low sodium? How do you know she has SIADH? What co-morbidities does she have? If she have no edema where is your evidence of excessive fluid? What is a high PVR?

Up Vote Up Vote ×

Okay, sorry.

If it helps here's my patients assessment by system or at least what was the most important I thought...

1.) Neurological:

- AOx3 as of 730

- AOx2 as of 1430 - My instructor think that was due to their dementia

- Glascow = 15

- Pupils = PERRLA

- LOC = Awake & Alert

2.) Musculoskeletal:

- History of Falls; scored an 85 on morse fall scale

- Active but requires assitive device or max supervision

- RUE = 5

- LUE = 5

- RLE = 3

- LLE = 3

3.) Diet / Fluids:

- Restriction:

- Intake: 450 mL as of 1240

- Output: 500 mL as of 1240 had a PVR of 295mL at 930 though. Assisted to bathroom every 2-3 hours.

- No catheter inserted; pt refused.

4.) Cardiovascular:

- DOE

- No neck vein distention. S1, S2 present. +2 pedal pulses

- Cap refill

- No edema present

- Amplitude, rhythm were regular & rate was at about 56.

Up Vote Up Vote ×

I never saw anything about dementia in the chart; however, the nurse told me she has a history of dementia. And as her sodium levels have been increasing, her symptoms haven't been improving. Which is why I assumed my patients neuro symptoms were r/t dementia as my nurse stated.

And since I saw no signs of edema I assumed she had excess fluid volume because of her poor appetite during both meals I documented which were below 40% which I forget to list, I'm sorry; however, my patient finished their drinks & kept asking for more drinks throughout the day. Which then I recommended the mouth swabs to help control their thirst.

Sorry if I'm being difficult, this is our first concept map :(.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

It's Ok we all had our first.

What care plan resource do you have?

Up Vote Up Vote ×

I have a nursing diagnosis handbook by Ackley, which I figured out how to use that one but just gives me interventions & a few nursing diagnoses for my specific condition. Diagnostic & Lab Test Reference by Pagana & A nurses handbook health assessment book by weber. Which our instructors haven't taught us how to use any of these :(

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I never saw anything about dementia in the chart; however, the nurse told me she has a history of dementia. And as her sodium levels have been increasing, her symptoms haven't been improving. Which is why I assumed my patients neuro symptoms were r/t dementia as my nurse stated.

And since I saw no signs of edema I assumed she had excess fluid volume because of her poor appetite during both meals I documented which were below 40% which I forget to list, I'm sorry; however, my patient finished their drinks & kept asking for more drinks throughout the day. Which then I recommended the mouth swabs to help control their thirst.

Sorry if I'm being difficult, this is our first concept map :(.

So you now say her Na levels are rising...we they low? Are they still low?

What was your actual assessment. Her vitals and labs. What did you see? What did she say? What was her admitting diagnosis? What meds is she on?

Critical Thinking Flow Sheet for Nursing Students(1).doc

Student Clinical Report Sheet(1).doc

Up Vote Up Vote ×
+ Join the Discussion