ScenarioThe purpose of a concept map is to visualize connections.docx

Scenario
The purpose of a concept map is to visualize connections
between ideas, connect new ideas to previous ideas, and to
organize ideas logically. Concept maps can be an extremely
useful tool to help organize and plan care decisions. By
utilizing a concept map, a nurse can simplify the connection
between disease pathways and emotional, cultural,
socioeconomic, and personality considerations that impact a
patient's health.
Instructions
Develop a patient-centered concept map for a chosen condition.
This could be a disease, or a disorder based upon the best
available evidence that has been individualized to treat your
patient's health, economic, and cultural needs. Write a brief 3–5
page narrative that explains why the resources cited in the
concept map and narrative are valuable and relevant. Describe
how you incorporated the patient's individual culture, identity,
abilities, and beliefs into the plan of care. Also, be clear about
your specific communication strategies for relating information
to the patient and their family.
The bullet points below correspond to grading criteria in the
scoring guide. Be sure that your map and narrative address all
of the bullets below, at minimum.
Part 1: Concept Map
Visit Healthy People 2030's
Browse Objectives page and select a topic.
· Design a patient-centered concept map based upon the best
available evidence for treating a patient's specific health,
economic, and cultural needs.
. Include objective and subjective assessment findings to
support three nursing diagnoses.
. Include interventions that will meet your patient’s individual
needs.

. Include measurable outcomes for each nursing diagnosis using
SMART goals: (S)pecific, (M)easurable, (A)chievable,
(R)elevant, and (T)ime-bound.
Part 2: Supporting the Concept Map
· Analyze the needs of a patient, and those of their family, to
ensure that the interventions in the concept map will be relevant
and appropriate for their beliefs, values, and lifestyle.
. Explain how you incorporated the patient’s individual culture,
identity, abilities, and beliefs into the plan of care.
. Consider how your patient's economic situation and relevant
environmental factors may have contributed to your patient's
current condition or could affect future health.
. Consider how your patient's culture or family should inform
your concept map.
· Apply strategies for communicating with the patient and their
family in an ethical, culturally sensitive, and inclusive way.
. Explain how you will communicate the proposed interventions
and evaluation plan in an ethical, culturally sensitive, and
inclusive way. Ensure that your strategies:
. Promote honest communications.
. Facilitate sharing only the information you are required and
permitted to share.
. Enable you to make complex medical terms and concepts
understandable to your patient and their family regardless of
language, abilities, or educational level.
· Explain the value and relevance of the resources you used as
the basis for your patient-centered concept map.
· Explain why your evidence is valuable and relevant to your
patient's case.
. Include a critique of the resources you used and specify the
level of evidence.
· Explain why each piece of evidence is appropriate for the
health issue you are addressing and for the unique situation of
your patient and the family.
. Include how the evidence was used to plan your interventions.
· Convey purpose of the assessment narrative in an appropriate

tone and style, incorporating supporting evidence and adhering
to organizational, professional, and scholarly communication
standards.
· Integrate relevant sources to support assertions, correctly
formatting citations and references using APA style.
The suggested headings for your paper are:
· Patient Needs Analysis.
· Communication Strategies.
· Value and Relevance of Resources.
Example Assessment: You may use the following to give you an
idea of what a Proficient or higher rating on the scoring guide
would look like:
·
Concept Map Exemplar [DOCX].
·
Concept Map Narrative Exemplar [DOCX].
Submission Requirements
· Length of narrative: 3–5 double-spaced, typed pages. Your
narrative should be succinct yet substantive.
· Number of references: Cite a minimum of 3–5 sources of
scholarly or professional evidence that support your evaluation,
recommendations, and plans. Current source material is defined
as no older than five years unless it is a seminal work. Be sure
you are citing evidence in both parts.
· APA formatting: Resources and citations are formatted
according to current APA style.
· Please submit both your concept map and your narrative as
separate documents in the assessment submissions area.
. You must submit both documents at the same time. Make sure
both documents are attached before submitting your assessment.
Remove or Replace: Header Is Not Doc Title

Example
Patient Scenario:
Ana is a 67-year-old Hispanic female. Ana was diagnosed
with diabetes 10 years ago. Ana reports that when she first
received this diagnosis she checked her blood sugar all the time,
that she “ate all sugar free food,” that she walked daily, and that
she never missed a dose of her medicine. In the past few years
Ana reports that she has “gotten so tired of it all,” and says
“there is nothing I can do, everyone in my family has diabetes
there’s no stopping it.” Due to increasing A1C, Ana was
recently started on insulin and reports she really didn’t want to
but “the doctor told me I had to, my blood sugars were too
high.” Ana reports she is trying to check her blood sugars and
take all her medicine, but has felt very busy sometimes
watching several of her grandkids unexpectedly due to school
closures due to COVID quarantines. Ana reports the family is
not comfortable seeking childcare and prefers to “keep the kids
safe with me.” She also states “I just get so busy I don’t have
time to check my blood sugar. I get so overwhelmed some days
I don’t even feel hungry, some days I don’t eat much.”
Per review of her medical record, Ana has not attended the
last two Primary Care appointments, is not returning calls, and
has not been reporting blood glucose readings. Ana reports last
week “I had to go to the hospital, the doctor needs to change my
insulin, it’s not right.” Ana reports her husband called 911 last
week because “I couldn’t answer him, he got scared and called
911.” Hospital records indicate Ana was found by EMS with
confusion and low blood sugar. She was treated for
hypoglycemia by EMS and taken to the hospital. She was
released the same day with instructions to see her primary care
doctor. The records also indicate Ana had arrived by EMS two
months ago for a similar episode. Ana states “I don’t have time
for all this medicine, but my family is worried about me.” Ana

reports after the last 911 call and ER visit that her she, husband,
and 3 kids got very scared, stating “I know I need to be more
careful and do better, I know that now.” Ana is here with her
husband and one of their daughters.
Nursing Diagnosis 2
Ineffective health management (Ladwig et al., 2019).
Nursing Diagnosis 3
Readiness for enhanced health management (Ladwig et al.,
2019).
Assessment Findings:
Patient seeking help to better manage blood glucose levels
Family supportive and concerned about patient
Sometimes does not check blood glucose before insulin dosing
Inconsistently taking oral diabetic medication
Feeling of hopelessness in managing diabetes diagnosis

Inconsistently incorporating treatment plan into ADL’s due to
overwhelming and unexpected responsibilities of caring for
multiple grandchildren
Feeling of hopelessness in managing diabetes diagnosis
Most Urgent Nursing Diagnosis
Risk for unstable blood glucose levels (Ladwig et al., 2019).
Ana
Type 2 Diabetic
Interventions:
Use a communication style that is person-centered, uses
strength based language and active listening to elicit patient
preferences, beliefs, and assess health literacy/numeracy and
barriers to care (ADAPPC, 2022a).
Assess for psychsocial and social determinants of health that
may compromise health (ADAPPC, 2022b)
Refer for Diabetes Self-Management Education and Support
(DSMES) (ADAPPC, 2022b)
Outcomes:

Patient reports health care goals are realistic and achievable
within next 6 months
Patient reports reduced stress over next 6 months.
Patient has reduced missed appointments from 2 missed in last 6
months to 0 in next 6 months.
Outcomes:
Patient reports health care goals are realistic and achievable
within next 6 months
Is registered for DSMES classes within 6 months by 8/1/2022.
Depression screening is completed by Behavior Health provider
at next visit with PCP (PCP visit 5/1/2022).
Interventions:
Promote strengths that patient has or has shown in the past to
manage health
Use a communication style that is person-centered, uses
strength based language and active listening to elicit patient
preferences, beliefs, and assess health literacy/numeracy and
barriers to care (ADAPPC, 2022a).
Outcomes:
Episodes of hypoglycemia will be reduced from 3 times per
month to 1 or less per month within the next 3 months.
Reduced A1C from 9.0 to 8.0 within 6 months by 8/1/2022.
(A1C goal currently 7.5 and goal may change after next PCP
visit).
Is registered for DSMES classes within 6 months by 8/1/2022.

Depression screening is completed by Behavior Health provider
at next visit with PCP (PCP visit 5/1/2022).
Interventions:
Address episodes of hypoglycemia at routine visits (American
Diabetes Association Professional Practice Committee
[ADAPPC], 2022d)
Discuss with PCP potential for relaxing glucose targets and
insulin titration (ADAPPC, 2022d)
Refer for Diabetes Self-Management Education and Support
(DSMES) (ADAPPC, 2022b)
Refer for depression screening (ADAPPC), 2022d)
References
American Diabetes Association Professional Practice
Committee. (2022)a. 4. Comprehensive medical evaluation and
assessment of comorbidities: Standards of medical care in
diabetes-2022.
Diabetes Care,
45(Supplement_1), S46–S59.
https://doi.org/10.2337/dc22-S004
Committee. (2022)b. 5. Facilitating behavior change and well-
being to improve health outcomes: Standards of medical are in
Diabetes-2022.
Diabetes Care,
Committee. (2022)c. 1. Introduction: Standards of medical care
in diabetes-2022.
Diabetes Care,

https://doi.org/10.2337/dc22-Sint
Committee. (2022)d. 13. Older Adults: Standards of medical
care in diabetes-2022.
Diabetes Care,
45(Supplement_1), S195–
S207. https://doi.org/10.2337/dc22-S013
Ladwig, G. B., Ackley, B. J., Flynn Makic, M.B., Martinez-
Kratz, M., & Zanotti, M. (2019).
Mosby's guide to nursing diagnosis (Sixth
ed.). Elsevier, Inc.
1
1
image1.emf
2
Support for Patient Centered Concept Map
Learner Name
Capella University
NURS-FPX6011 Evidence-Based Practice for Patient-Centered
Care and Population Health
Instructor Name
Date
Concept maps are a tool that can be used to develop an

individualized plan of care. Evidence-based practice should
support the planned interventions to meet the patient’s needs.
The attached concept map was developed to plan care for a
diabetic patient who has been non-compliant with her self-care
regimen.
Patient Needs Analysis
The most important nursing diagnosis for this patient is Risk for
unstable blood glucose level
(Ladwig et al., 2019). The patient has reported several
factors that put her at risk for this diagnosis. She has had
episodes of hypoglycemia where her family has called 911 and
has continued to have difficulty with blood glucose monitoring
and reports not eating well. She is reporting declining interest
in overall diabetes management over the past few years. The
second most important nursing diagnosis is Ineffective health
management
(Ladwig et al., 2019). The patient has reported feeling
an overall loss of interest and hopelessness in meeting glycemic
goals over the past few years. Additionally, she has reported
feeling overwhelmed with taking care of her grandchildren
which has been intermittent and unexpected due to school
closures related to COVID 19. The third diagnosis that is
appropriate for Ana is Readiness for enhanced health
management
(Ladwig et al., 2019). Ana is seeking care and help
now because she recognized her choices are not healthy for her
and she is concerned as well as her family.
According to the American Diabetes Association
Professional Practice Committee (ADAPPC) standards of care
“Significant changes in life circumstances, often called social
determinants of health, are known to considerably affect a
person’s ability to self-manage their condition” (ADAPPC,
2022b). COVID has had a significant impact on individuals,
families, and communities. This patient and her family have

been impacted and it is contributing to the patient’s ability to
effectively manage her diabetic diagnosis. According to the
ADAPPC, “There are four critical times to evaluate the need for
diabetes self-management education to promote skills
acquisition in support of regimen implementation, medical
nutrition therapy, and well-being: at diagnosis, annually and/or
when not meeting treatment targets, when complicating factors
develop (medical, physical, psychosocial), and when transitions
in life and care occur” (2022b). This patient and family are
experiencing at least two out of four of these critical times.
The intervention to refer for Depression screening and Diabetes
Self-Management Education and Support (DSMES) will begin to
address some of these barriers.
Communication Strategies
The patient has expressed the desire to implement changes
to improve diabetic goals. What providers and healthcare staff
feels the patient can and should do may not be in line with what
is realistic and desired for the patient. It is critical that
encounters with this patient promote empowerment and reduce
unintentional discouragement. According to the ADAPPC
standards of care “A patient-centered communication style that
uses person-centered and strength-based language and active
listening; elicits patient preferences and beliefs; and assesses
literacy, numeracy, and potential barriers to care should be used
to optimize patient health outcomes and health-related quality
of life” (2022a). Furthermore, the actual language used during
encounters is also important. A task force made up of the
American Association of Diabetes Educators and the American
Diabetes Association representatives submitted a consensus
report outlining recommendations in the use of language in
diabetic care and education (Dickinson et al., 2017). The
outcome from this consensus report includes five main
recommendations. Language used by health care team should
be 1) neutral, nonjudgmental, based on facts, 2) free from
stigma, 3) strength based, respectful, inclusive and imparts
hope, 4) fosters collaboration and 5) is person centered

(Dickinson et al., 2017). Some specific examples include
replacing terms such as “non-compliant” with fact-based
language such as, “she has not taken her medication because…”,
replacing “diabetic person” with Person with diabetes and “Are
you diabetic?” with, “Do you have diabetes” (Dickinson et al.,
2017).
The patient is the matriarch of her family. The family has
a close relationship with her three children, visiting multiple
times per week and sharing meals at least once every weekend.
The patient reports caring for her grandchildren is a stressor,
however she does not want them to be cared for by someone
outside the family. Generally speaking, close familial ties are
common in Hispanic culture; therefore it is important to address
this barrier while honoring the cultural responsibilities the
patient is feeling.
Areas of uncertainty include whether individualized
glycemic goals are medically feasible. According to the
ADAPPC standards for older adults, “Glycemic goals for some
older adults might be reasonably relaxed as part of
individualized care, but hyperglycemia leading to symptoms or
risk of acute hyperglycemia complications should be avoided in
all patients” (ADAPPC, 2022d). The patient has commented
she did not want to start insulin, so an open discussion about
this with the Primary Care physician could be helpful. Another
area of uncertainty is the extent of how much other family
members can help with the burden of childcare. The effect of
COVID-19 on school systems is an ever-changing factor and the
likelihood of school closures and student quarantines remains
ever present. It is also uncertain how this will affect the
patient’s ability to make routine appointments and diabetic
education classes. There are telemedicine options available
which could help overcome some barriers, but the patient’s
comfort with video visits and video classes is yet to be
assessed.
Value and Relevance of Evidence
Many resources used as the basis for the patient centered

concept map are standards of care developed by the American
Diabetic Association. These standards are not meant to
“preclude clinical judgment and must be applied in the context
of excellent clinical care, with adjustments for individual
preferences, comorbidities, and other patient factors”
(ADAPPC, 2022c). The American Diabetic Association uses an
evidence based grading system to categorize these practice
standards with “A” being the highest level of evidence and “ E”
being the lowest level of evidence ” (ADAPPC, 2022c).
“Recommendations with “A” level evidence are based on large
well-designed clinical trials or well-done meta-analyses.
Generally, these recommendations have the best chance of
improving outcomes when applied to the population for which
they are appropriate. Recommendations with lower levels of
evidence may be equally important but are not as well
supported” (ADAPPC, 2022c). Diabetes can be difficult to
manage for patient and their families, the ADA Standards for
Medical Care in Diabetes have been continually improved for
over 30 years and are a go to resource for health care
professionals (ADAPPC, 2022c).
Conclusion
The patient’s individual values, beliefs, and lifestyle must
be considered in order to provide individualized care. Using
evidence-based practices ensures we are using the most up to
date and reliable resources to guide our care. Finally, we must
utilize effective communication strategies to support patient
understanding and their compliance with the recommended
interventions.
References
Committee. (2022)a. 4. Comprehensive medical evaluation and
assessment of comorbidities: Standards of medical care in
diabetes-2022.
Diabetes Care,
45(Supplement_1), S46-S59.

Committee. (2022)b. 5. Facilitating behavior change and well-
being to improve health outcomes: Standards of medical care in
diabetes-2022.
Diabetes Care,
Committee. (2022)c. 1. Introduction: Standards of medical care
in diabetes-2022.
Diabetes Care,
https://doi.org/10.2337/dc22-Sint
Committee. (2022)d. 13. Older adults: Standards of medical
care in diabetes-2022.
Diabetes Care,
45(Supplement_1), S195–
S207. https://doi.org/10.2337/dc22-S013
Dickinson, J. K., Guzman, S. J., Maryniuk, M. D., O'Brian, C.
A., Kadohiro, J. K., Jackson, R. A., D'Hondt, R.
A., Montgomery, B., Close, K. L., & Funnell, M.
M. (2017). The use of language in diabetes care and education.
Diabetes Care,
40(12), 1790–1799.
https://doi.org/10.2337/dci17-0041
Ladwig, G. B., Ackley, B. J., Flynn Makic, M. B., Martinez-
Kratz, M., & Zanotti, M. (2019).
Mosby's guide to nursing diagnosis (6th ed.). Elsevier,
Inc.

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