chapter 3 concept mapping: grouping clinical data in a meaningful manner 劉芹芳 楊玉娥...
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Chapter 3 Concept Mapping:
Grouping Clinical Data in a Meaningful Manner
劉芹芳楊玉娥周汎澔林麗娟
Objectives1. Identify the ANA nursing standard of care related to
organizing patient data. 2. Identify primary medical diagnoses.3. Review patient profile data to determine general health
problems.4. Categorize patient profile data under health problems
resulting from the patient’s response to the health problem.
5. List primary assessments associated with the medical diagnosis.
6. Label nursing diagnoses.7. Specify relationship between nursing diagnoses.
Concept Map
Assessment data
(use critical-thinking
skills to organize data)
Nursing diagnoses
3 Steps to Develop a Concept Map
1. Develop a basic skeleton diagram (to formulate initial impressions of the clinical patient profile data)
2. Analyze and categorize data (to arrange data in hierarchical order)
3. Label diagnoses—Analyze relationships between problems (to make meaningful associations between segments of the map)
Scenario
Age: 80 y/o Sex:M Admission date: 3/21住院原因: Diabetes醫學診斷: New onset diabetes( defined
above) History of hypertention
Laboratory data : blood glucose : 450
glycohemoglobin : 12 % cholesterol : 240
urine analysis : 3+ sugar,
no ketones,
no protein,
no WBCs,
clear yellow
Scenario— 續
Medications
Humulin N 35U q.A.M., 7 : 30 A.M.
Valsartan 80mg q.A.M., 9 A.M.
Acetaminophen 650mg, q4h, p.r.n.
Treatments
Accu-check q.i.d., ac & hs
Support Service : Dietary
Consultations : Diabetes educator
Scenario— 續
Type of diet : 1800 ADA Intake : 2200 Problems : swallowing, chewing, dentures ( nurse’s notes ) Needs assistance with feeding ( nurse’s notes ) Nausea or vomiting ( nurse’s notes ) Overhydrated or dehydrated ( evaluate total I/O ) Belching
Other : history of polyphagia Urine Output : 1800
Scenario— 續
Activity : Weakness
Physical assessment
BP : 138/92
TPR : 98.4 – 77 – 19
Height : 175 ㎝ Weight : 79 ㎏
Scenario— 續
Neurological/Mental Status
alert and oriented to person, place, time
Religious preference : Catholic Marital Status : Widower Occupation : Retired Emotional state : Anxious about giving insulin and following diet
Scenario— 續
Step 1-1 Develop a Basic Skeleton Diagram
Database for Patient with Diabetes
Step 1-1: Develop a basic skeleton diagram
Map the framework of propositions
a. find patient’s key problems
concepts
b. start by centering the medical diagnosis
Newly Diagnosed Diabetes
Nutrition
Learning
Anxiety BP problems
Elimination
Step 1-2 Looking Up Information
Drugs Laboratory and Diagnostic Tests Diet Medical Diagnoses
Step 1-3Preventing Falls and Skin
Breakdown
Assessment Directions
Place an “x” in front of elements that apply to your patient. Based on the assessment, check whatever applies to the patient. A patient for whom you place four or more “x” marks is at risk for falling
General Data
X Age over 60
__History of falls before admission
__Postoperative/ admitted for operation
__Smoker
Physical Condition
__Dizziness/ imbalance
__Unsteady gait
__Diseases/ other problems effecting
weight-bearing joints
X Weakness
__Paresis
__Seizure disorder
__Impairment of vision
__Impairment of hearing
__Diarrhea
X Urinary frequency
Medications
__Diuretics or diuretic effects
X Hypertensive or CNS suppressants drugs
__Postoperative/ admitted for operation (e.g., narcotic, sedative, psychotropic, hypnotic, tranquilizer, antihypertensive, antidepressant)
__Medication that increase GI motility
Ambulatory Devices Used
__Cane
__Crutches
__Walker
__wheelchair
__Geriatric (geri) chair
__Braces
Mental Status
__Confusion/ disorientation
__Impaired memory r judgment
__Inability to understand or follow directions
Step 2: Analyze and Categorize Data
圖 3-1
Not Sure:Skin breakdown ?
Newly Diagnosed Diabetes
AnxietyBP Problems138/92
NutritionPolydipsiaI =2200O =1800Weakness 79 ㎏
EliminationI =2200O =1800Polyuria Learning
Figure 3-1
Step 3 : Label Diagnoses—Analyze
Relationships between Problems Many students have a tendency to select nursing diagnoses too quickly, without first looking at and organizing all data.
1.NANDA system
2.Gordon’s Functional Health Patterns
3.NANDA’s Human Response Patterns
Figure 3-4-1
Figure 3-4-2
Summary Psychosocial-cultural assessment -- 請看 Chapter 6
The purpose of this chapter was to take you slowly through the first three step of the concept map care planning process.
自行練習:請參考附件