285_concept_map_info_285 NURSING PROCESS PAPERS: CONCEPT MAPPING The Nursing Process: Assessment, Nursing Diagnosis, Goals, Interventions, and Evaluation.

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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 Databa... se 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. • Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …” • List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are supposed to be carefully monitoring, treatments, patient education, and medications. • Be complete and think, “What am I doing this day for this patient/client”. • Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day. STEP 5: EVALUATE PATIENT’S RESPONSES (Example #4) • As you complete a nursing intervention, write down the patient’s responses. • Evaluate the goal: was the goal met or not? Do the nursing interventions need to be revised? • This step also involves writing you clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about. [Show More]

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