gathering clinical data: the framework for concept map care plan...
Post on 19-Dec-2015
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Importance
Good clinical judgments are based on accurate and complete data collection.
Purpose of this section: To provide guidelines for collecting relevant
clinical data.
Objective: To decrease overwhelmed feeling about
collecting data. To promote student’s ability to make good
clinical judgment.
Finding important data
Reference and responsible persons: Student nurses, clinical faculty, nursing staff
Where to look for data? Many students are not familiar with data
sources. Many students cannot read the writing or
understand the abbreviations. Data are everywhere!!
Just have to find it! Solution.….Patient profile database
Patient profile database
Characteristics: The database has physical,
psychological, social, and cultural components.
99% of data can be collected from patient notes and records;
1% from conversations with patients and the assigned nurse.
Components of the patient profile database
All medical problems must be identified and
defined.(Kardex & Chart)
Abbreviations & poor handwriting is a common
problem
Surgical consent & Kardex(different)
Component: Medication
Sources: Chart, Kardex, Medication record 6 rights
Drug, patient, dose, route, time right, right to refuse a medication.
Other: Allergies, pain medications pain rating
由藥物類別、作用連結到個案的健康問題 concept map care plan
Component: Treatment Sources: Chart, Kardex
1. Record treatments, support services (ie. PT, OT, ST, RT, SW), consultations
2. IV therapy (type/rate, IV site, other)
Know why the patient is receiving the treatment
由治療作用連結到個案的健康問題 concept map care plan
Component: Elimination Sources: Chart, flow sheet1. Bowel
1. Last bowel movement2. Problems: constipation, diarrhea, flatus, incontinence, belchin
g2. Bladder
1. 24-hour urine output2. On Foley/condom catheter3. Problems: hesitancy, frequency, burning, incontinence, odor
3. Other 由評估結果連結到個案的健康問題 concept map care
plan
Component: Activity Sources: Kardex, flow sheet
1. Ability to walk2. Type of activity orders (different!)3. Use of assistive devices4. Fall-risk assessment rating5. Side rails6. Restraints7. Weakness8. Trouble sleeping
由評估結果連結到個案的健康問題 concept map care plan
Physical Assessment Data:BP, TPR, BH, BW, Neurological/mental status, musculoskeletal system, cardiovascular system, respiratory system, gastrointestinal system, skin and wounds, eyes, ears, nose, throat
Psychosocial-cultural component and additional information
Sources: Chart, Nursing notes1. Religious preference2. Marital status3. Health-care benefits and insurance4. Occupation5. Emotional state
Additional information Assessment- Fall risk, pressure ulcer, skin Standardized nursing care plans Clinical pathway Patient education materials
Remarks• Conclusions
• Patient profile database is comprehensive and systematic
• 由評估結果連結到個案的健康問題 concept map care plan
Obstacles Time consuming Completeness
undetermined Inappropriate linkage
to health problems Unreachable sources
What else?