chapter 3 concept mapping: grouping clinical data in a meaningful manner 劉芹芳 楊玉娥...

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