• Are not as abstract as they seem• The concept map is a visual of all your patient’s problems.• The care plan is just your plan of care for your patient!
• Who is your patient?• What is the medical diagnosis?• What are the patient’s presenting symptoms?• What does the assessment ‘say’ about the patient?• The review of systems?• The vital signs?• Any social, cultural, psychologi cal or spiritual concerns…
• The concept map• The care map• The concept care map• Yeah, that thing…
• They promote critical analysis• They help clarify nursing diagnoses• It takes the guesswork out of the picture
• Based on the patient’s reason for seeking care. • Based on the assessment and vital signs. • Based on the medical diagnosis, labs, tests,Vital signs 96.4 R, 68/48, P- 170, R-80 medications and32 week premie, treatments.Mother SROM, meconium stained,Beta strep positive – no treatment • Write this information on the concept map.
• Social isolation• Altered nutritional status• Ineffective tissue perfusion• Altered fluid and electrolytes• Impaired tissue integrity• At risk for infection
• It is impossible to develop an individualized plan of care unless you have identified and prioritized the patient’s problems.• The medical diagnosis focuses on the signs and symptoms of the pathological process.• Nursing diagnoses focus on patient responses to health problems.
• Look for linkages and associations.• Define your nursing diagnoses.• Prioritize!• The #1 problem usually has the most supporting data.
• Identify therapeutic goals, outcomes and strategies to address each nursing diagnosis.• Set mutual goals with your patient.• Interventions help meet these goals.• Lastly, evaluate your care.
• My patient will: • My patient’s pain level• Experience bonding will be <3 before shift and physical touch change. with parents for 30 minutes today.• Consume 40% of their meals today.• Maintain oxygen saturation levels of >95% today.
• Assess, observe for signs and symptoms of problems.• Administer medications, treatments, oxygen, suctioning.• Provide comfort The infant will be assessed hourly O2 as needed, thermoregulation, measures, therapeutic Pacifier provided, feeding via NG tube communication. Parents encouraged and advised about therapeutic touch, hand washing• Teach patient and family as needed.
• Lastly, care will be evaluated.• Goals were met or not met.• What went well and was successful.• What was not accomplished and may need amending.
• Gather data• Identify problems on concept map• Translate problems into nursing diagnosis• Set goals• Intervene• Evaluate