Care plans and concept maps resources

RainMom · Dec 22, 2014

You might be getting a little ahead of yourself. Give your instructor(s) a chance to lay it all out for you. I know I had looked ahead at care plans before starting school & it was a big jumble & made no sense.

Going into it, just know that:

1- a good assessment is key to gather your data

2- develop a problem list (from your data) for the pt which is where your nursing dx comes from

3- what is it that you, as the nurse, are able to do (interventions) to improve the pt's situation/symptoms

4- Care plans are not the devil ;-)

Every instructor has different expectations & there will probably be slight differences in your care plans depending on who will be grading them.

Esme12, ASN, BSN, RN · Dec 22, 2014

Hey everyone! Soon I will be beginning my second semester of my ABSN program (YAY!)
This semester I'll have acute/chronic, which I believe is the same as med/surg...
Anyway, I'm hearing a lot about having to create care plans and concept maps so I wanted to use this time to get a head start and learn how to write them. I don't have my textbook list yet. Can anyone recommend good resources for making both of these items? I've read on here that the Nanda book on Amazon is popular (see link below), but that doesn't give any rationalization so...I'm looking for other resources.
TIA!
Nursing Diagnoses 2015-17: Definitions and Classification (Nanda International): 9781118914939: Medicine & Health Science Books @ Amazon.com

Ok, first...that NANDA book is THE resource. Once you get it and get started in school you will see why.

Second is knowing how to obtain the proper information in your assessment and research in the chart. See on my sig line I have 2 attachments that will guide you through this process that was developed by a beloved member (rip) Daytonite.

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

I also recommend a nursing care plan book like Ackley, who recently passed away...Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care that also has an online care plan constructor.

now when you get your first patient and need a care plan....come back and we can help guide you through....it is what we do...l.((HUGS))

This is an excellent care map resource...Concept Mapping

NurseSN45696 · Dec 23, 2014

Thank you both :)

nurseprnRN, BSN, RN · Dec 31, 2014

There are two other books that will help you. See towards the end.

(And I do't know what you mean when you say the NANDA-I 2015-2017 (the current edition, which you must get) "doesn't give any rationalization.") This new edition gives lots and lots of literature links with rationales for each nursing diagnosis, though.

Now, as to nursing diagnosis and NANDA-I...

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.