concept maps.docx - concept maps-A different approach to...

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concept maps -A different approach to planning and organizing nursing care -organize patient data -analyze relationships in the data -establish priorities -build on previous knowledge -identify what you dont understand -enable you to take a holistic view of the patients situation -participate in developing a shared mental model of the patient's health status and situation with members of the healthcare team Nursing Process Assessment Diagnosis Planning Implementation Evaluation Data Colellection -Confidentiality -Demographics (Admission date, age, gender, marital status, religion) -Reason for hospitalization -past medical history/surgical history -allergies -advance directions -Labs CBC inflammation and infection hbg and hct anemia and bleeding blood coagulation platelets PT (prothrombin time) INR (international normalized ratio PTT (partial thromboplastin time) kidney function BUN Creatinine Liver function Bilirubin Electrolytes sodium potassium calcium glucose lab measurement used to check for diabetes
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medications Right drug Right patient Right dose Right route Right time Right to refuse Diet type NPO, Clear liquid, Soft, low-fat, low-protein, low-residue, tube feeding activity In data collection it is important to note a patient's ______ level or if there are any restrictions subjective data info that the patient describes objective data observable or measured facts Step 1 Basic Skeleton: Why is the patient here: reason for seeking health care What are the clinical problems step 2 Analyze and categorize group and cluster the data that are the most important related to the patients reasons for seeking care support problems identified with clinical patient data step 3 label and analyze relationship -label each category with the appropriate nursing diagnosis -prioritize the nursing diagnosis from most important to least -draw line between the nursing diagnosis to indicate relationships -be able to explain the relationships step 4 Identify goals, outcomes, strategies/documentation -SMART -list the nursing strategies that you will implement to help achieve each goal -understand rational step 5 Evaluate the patient's respones Goals, outcomes, strategies
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-joint effort by nurse and pt -agreed upon priorities (maslow) -SMART -Strategies (Independent, Collaborative, Delegation) -focus on resolving problems and meeting patients needs evaluation -what was the pt's response to the strategies? -Does the problem need to be redefined? -are the outcomes realistic? -do priorities need to be reordered? -are there new problems to consider? -what factors impacted the achievement or lack of achievement of the goal? Teaching plan Adherence The extent to which and individuals behavior ( for example taking medications, following diets, or making lifestyle changes) coincides with medical or health advice; commitment or attachment to a regimen Affective Domain Known as the "feeling" domain and is divided into categories that specify the degree of a persons depth of emotional response to tasks; includes feelings,
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