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285_concept_map_info_285 - NURSING PROCESS PAPERS CONCEPT...

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NURSING PROCESS PAPERS: CONCEPT MAPPING The Nursing Process: Assessment, Nursing Diagnosis, Goals, Interventions, and Evaluation. PREPARATION: ASSESSMENT PHASE. Using the Patient Profile Database gather clinical data: report from Clinical Professor and/or primary nurse, assess the patient, and review the patient records, laboratory data, medications, and treatments. STEP 1: DEVELOP A BASIC SKELTON DIAGRAM (Example #1) Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care. In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis). Around this central diagnosis, arrange general problems (these will become the nursing diagnoses) that represent your patient’s responses to this reason for seeking health care (usually the medical diagnosis). STEP 2: ANAYZE & CATEGORIZE THE DATA (Example #2) Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses. Data can be listed in more than one area if it is relevant to more than one category. If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor. Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map. STEP 3: ANALYZE NURSING DIAGNOSES RELATIONSHIPS (Example #3) Draw lines between nursing diagnoses to indicate relationships. Label the general problems you have identified according to the North American Diagnosis Association (NANDA) classification system and number them. Think ABC (airway, breathing, & circulation). STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS (Example #4) On a separate piece of paper, for each nursing diagnosis write your patient goals/outcomes.
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