CONCEPT MAP AND CARE PLANNING

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CONCEPT MAP AND CARE PLANNING
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ANA Policy Statement

• Nursing is the diagnosis and treatment of human
  responses to actual or potential health problems

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Human Responses

• NANDA
• North American Nursing Diagnosis
• Association
• Exchanging
• Communicating
• Relating
• Valuing

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Human Responses

• Choosing
• Moving
• Perceiving
• Knowing
• Feeling

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Human Responses

• Maslow Human Needs
• Medical Model/Body System
• Gordons 11 Functional Health Patterns

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Nursing Process

• Assessment
• Nursing Diagnosis
• Planning
• Implementation
• Evaluation

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Assessment

• Collect and examine information (data)

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Diagnosis

• Analyze data to identify human responses and
  alterations and determine need for action

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Planning

• Develop a plan with goals and interventions that
  will meet needs of customer

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Implementation

• Put the plan into action and document what you do
• Evaluation
• Determine if plan worked to meet goals.
• If not , which goals were met and which
• were not
• Evaluate each goal, not each action

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Professional Nursing Practice

• Independent what the nurse can do on her own
• Interdependent getting the whole healthcare
  team involved
• Dependent the nurse cannot do this on her own
  and must collaborate with providers

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Bifocal Clinical Practice

• Describes two areas
• Nursing Diagnoses
• Collaborative Problem
• Problem List Includes all problems written
  completely and listed in order of priority

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Which type of problem is it?

• Identify the problem
• Can the nurse treat this problem independently?
• If the answer is
• Yes Nursing Diagnosis
• No - Collaborative Problem

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Nursing Diagnosis (ND)

• P Problem
• E Etiology/Factors
• S Signs and Symptoms

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Nursing Diagnosis

• Actual the problem is present and the nurse
  tries to get rid of it.
• Potential factors are present that may lead to
  a problem, so the nurse tries to eliminate or
  reduce these factors to prevent the problem from
  happening

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Nursing Diagnosis Development

• Example client has pneumonia, is coughing
  excessively and has difficulty maintaining a
  patent airway due to thick mucus secretions.
• Human response fits under activity-exercise
• Which label listed is best for this problem?

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• Ineffective airway clearance is A state in
  which an individual is unable to clear secretions
  or obstruction from the respiratory tract to
  maintain airway patency
• Ineffective airway clearance is a diagnostic
  category label
• Follow the label with related to R/T

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ND Development

• The nurse must be able to list actions that treat
  or reduces the factor or R/T
• The medical diagnosis is not the contributing
  factor for the R/T but it could be listed as
  secondary to or (2)
• The nurse cannot treat medical diagnosis
  independently so it cant be R/T
• Example Ineffective airway clearance R/T thick
  mucus secretions 2 to pneumonia

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• Nurse cannot treat the pneumonia but can treat or
  affect the thick mucus secretions with fluids,
  mobility etc.
• Signs and symptoms are cues of the problem,
  listed after AMB
• No symptoms No actual problem
• Goal should focus on reducing or eliminating the
  signs and symptoms

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• If S S are present then it is always an actual
  problem not potential or high risk for!

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High Risk For

• If the etiological, related to factors, are
  present but there are no signs and symptoms, then
  the problem has yet to occur but the patient is
  at risk of developing the problem
• The nurse plans to eliminate or reduce the
  factors impacting the client to prevent the
  problem from occurring

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Complete Nursing Diagnosis

• Ineffective airway clearance R/T thick mucus
  secretions 2 pneumonia AMB excessive coughing ad
  inability to maintain a patent airway
• P Problem Diagnostic category label
• E R/T Etiological or contributing factors
• S AMB Signs and symptoms exhibited

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Collaborative Problem (CP)

• Complications that nurses monitor to detect
• Nurses manage collaborative problems in
  collaboration with the healthcare team

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Main Difference ND and CP

• Difference is
• ND only the nurse prescribes the treatment
• CP the treatment comes from both nursing and
  medicine or other discipline
• Format is Potential Complication Complication
• PC Complication

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Collaborative Problems

• Myocardial Infarction
• Potential Complication Dysrythmia
• Loop Diuretic
• Potential Complication Hypokalemia
• Cardiac Catheterization
• Potential Complication Hemorrhage

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Outcomes or Goals

• Long and Short Term
• Relates to signs and symptoms
• Realistic statement that is Client Family focused
  for ND or Nurse focused for CP

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Outcomes or Goals

• Behaviorally stated and measurable
• Each goal must have a timeline
• Prefer 24 hour plan, not my shift on same day or
  my care
• Use timeline for completion such as a specific
  date, DHS or DOD
• Dont use words that cannot be measured
• understands, knows, believes, perceives

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• Use measurable words such as verbalizes, states,
  performs, demonstrates, lists
• Start with client will or family will..
• Long Term Goal at least several weeks or months
  from discharge more general statement of
  function
• Client will complete activities of daily living
  independently by 4 weeks from discharge

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• Short Term Goal needed to be met in order for
  patient to be discharged
• Goal is opposite of signs and symptoms in ND
• Patient has congested lungs, Goal is client will
  demonstrate clear lungs to auscultation by DOD
• PC Pneumonia
• The nurse will monitor to detect symptoms of
  pneumonia and communicate/collaborate with the
  health care team DHS

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Interventions

• Nurse actions
• Based on principles
• Each has a rationale
• Text with author and page number for each
• Individualized

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Implementation

• Lists exactly how the intervention was
  implemented
• The nurse would document any intervention
  implemented in the client record, forms, flow
  sheet or narrative

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Evaluation

• Does not relate to each intervention implemented
• One overall statement for each problem that
  related directly to goal or outcome
• States Goal Met, Goal Partially Met or Goal Not
  Met with evidence
• Usually restates the goal

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CONCEPT MAPS

• Facilitate critical thinking and decision making
• Abstract compared to care plans
• Helps to correlate the patients medical and/ or
  nursing diagnoses, symptoms, treatments, and
  interventions, and goals.
• Creative!