Question about concept map

classicdame, MSN, EdD · Feb 18, 2013

sounds like homework???

Rg0709 · Feb 18, 2013

yes it was... I was just making sure I was on the correct path. If I could have made improvements than I would have had an idea in which direction to go and to know if I was doing it wrong... :-)

inforthelonghaul · Feb 18, 2013

It's important to know that there can be different organization depending on your rational. So it's more important to have a valid rationalization than it is to have the one and only correct response. Just don't forget your ABCs and be ready to give your reason for the prioritization that you choose.

Esme12, ASN, BSN, RN · Feb 18, 2013

What semester are you? Is this a real patient? Care maps are just like care plans but in a different layout/format.

Welcome to an!!!!!

Concept mapping a great resource on care maps step by step.

The biggest thing about a care plan/map is the assessment. The second is knowledge about the disease process. First to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs.the medical diagnosis is what the patient has and 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.

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 them as a recipe to caring for your patient. Your plan of care.

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. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is 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.

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:

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)
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)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

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 a medical disease, a physical condition, a failure to be able 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 aims 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 a detective and always be on the alert and lookout for clues. At all times. And that is within the spirit of step #1 of this whole 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. 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.

care plan reality: is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every NANDA nursing diagnosis has a definition). [thanks daytonite]

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.

What is bradycardia? What happens with bradycardia? What can happen to a patient with Bradycardia?

Admitted for hardware failure with a secondary Dx of bradycardia. prev illness of chronic kidney disease, diabetes type 2, hypertension, anxiety, depression, schizophrenia, paroxysmal tachycardia.

This gives my what the patient has....now what do you need to look at for what the patient needs. Tell me about your patient. What care plan book do you use?

Rg0709 · Feb 18, 2013

I am currently in my second semester and yes this was real... I wrote down all kinds of information and even lab values and abnormal values. I was having a hard time deciding which would be a priority. I had so much information and trying to put the drugs that go with the abnormal values was so much information and just a complete overload.. but I know the more I do and the more understanding I get from doing all of this research may make it a little bit easier in time..

But thank you so much for your input. I will have go back over it all and follow some of your input so maybe I can get a better insight to it all.. :-)

Esme12, ASN, BSN, RN · Feb 19, 2013

So many CI are giving imaginary scenarios and I think it males it difficult for students as they are just learning....care plans are all about the patient.

Use your information about your patient.....Think about.....what would kill them first. Write a scenario about your patient here and see if we can lead you in the right direction. Your patient data gives you the priority......

patient was admitted for hardware failure with a secondary Dx of bradycardia. prev illness of chronic kidney disease, diabetes type 2, hypertension, anxiety, depression, schizophrenia, paroxysmal tachycardia.
So I have #1 decreased cardiac output #2 Falls #3 self-care deficit #4 fluid retention #5 constipation #6 anxiety #7 risk for bleeding #8 risk for infection.

If this patient admitted with hardware failure is a failed pacemaker with an intrinsic heart rate of 20......that is a significant problem. What evidence do you have that proves that this is the most important for this patient. Are the plans to change the pacemaker? Have the changed the pacemaker? Is this patient now post op after re-insertion of a pacemaker? What would you look at for a fresh post op pacemaker?

Out of the co-morbidities of this patient which are active? What are their labs....what is their kidney function? Are their sugars under control?

What evidence do you have that your patient has falls, self care deficit, fluid retention, constipation...etc. Would fluid retention possibly be more of a priority if it is a representation of fluid over load and heart failure?

Look at your data....look at maslows

what will kill them first

Rg0709 · Feb 19, 2013

Most of that information was because i witnessed it... fluid retention per bladder scan, constipation...and for self care deficit pt wasn't able to move from bed unless assisted with physical therapy... so I am very thankful that I have a real patient so I have the opportunity to try and figure this out and being able to put the pieces together. So much to learn in this field!!! but I love it.. :-)

Esme12, ASN, BSN, RN · Feb 19, 2013

Fluid retention I know can also be the accumulation of fluid in body cavities but why was there urine on the bladder scan. Did they have to go to the bathroom or is this a urine retention issue.....for it would change the priority.

Was there any peripheral edema? to indicate fluid overload from the decreased cardiac output related to the bradycardia?

For self care deficit...why does the patient need PT assistance? Weakness? SOB? Fatigue? Can they wash and feed themselves? Just needing PT isn't sufficient enough...WHY do they need PT is important.

Give me details and I can help you more accurately.

Rg0709 · Feb 19, 2013

she needed to use restroom, but couldn't.. Foley was just taken out. Tried to do straight cath to remove fluid, but only 450cc was removed. so had to redo foley to remove 750mL... I don't don't know why she was retaining it. she did have edema on lower extremities and on her hands. she had surgery on her rt hip so she wasn't able to move out of bed without assistance from physical therapy. she was extremely weak and had tremors in her hands. she minimal pain because of meds. I am still not sure what the bradycardia was related to. that was just here secondary diagnosis. her pulse would change from 78 to 68 within an hr. I never witnessed her feeding herself, always someone doing it for her.... her H & H were low... her sodium was always low her GFR always low.. and her creatinine serum was always high....

Esme12, ASN, BSN, RN · Feb 19, 2013

This changes everything. YOu have fallen into the trap that catches all students.......taken your nursing diagnosis from the medical problems instead of from your assessment.

For you next patient or even for this one.....use these information organization sheets to help organize your assessment data and information from a beloved member Daytonite (rip)

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

So her failed hardware is in her hip? She is a post op? What would be important to a post op? Why would she have edema? What is a low GFR significant of? What effect does major surgery have on the elderly? Could some of her weakness be caused by anemia from surgery? Urinary retention can be a complication of having the foley and old age as the bladder loses tone. If she isn't eating well then she has imbalanced nutrition.

What care plan book do you use? For every diagnosis you use you have to have evidence in your assessment that proves your statement.

For example: #1 decreased cardiac output

NANDA I describes decreased cardiac output as.......Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

With the Defining Characteristics of.....or As evidenced by........

Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional: Anxiety; restlessness

Related Factors (r/t): Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

Then you have falls....what evidence do you have for falls...... has she fallen or is she at risk for falls.

She may have a self care deficit but she also has activity intolerance. She has acute pain ....even if medicated she has pain. Anxiety what evidence do you have for anxiety. Knowing that her kidney function tests are high...this means she has renal insufficiency or renal failure.....what impact will this have on her healing? Is she on any anti-psychotics that can affect her recovery process? If she didn't have bradycardia for your assessment...can you have that as a part of your care plan?

Here is what I see from what you have told me.......I use Ackley: Nursing Diagnosis Handbook, 9th Edition care plan book

Activity intolerance

Impaired Comfort

Constipation

Excess Fluid volume

Impaired physical Mobility

Acute Pain

Bathing Self-Care deficit

Impaired Skin integrity

Delayed Surgical recovery

Impaired Urinary elimination

Urinary retention

Risk for unstable blood Glucose level

Risk for Falls