NRST 2730: Clinical Experience III

Daily Care Plan Utilizing Concept Mapping to Promote Critical Thinking

1. A concept map is the plan used to give daily nursing care. It must be practical and realistic;
it will be implemented and evaluated during the clinical day. Developing concept care maps
will enhance your critical thinking skills and clinical reasoning, because you will visualize
priorities and identify relationships.

2. Concept care maps are used to:

a. Organize patient data

b. Analyze relationships in the data

c. Establish priorities

d. Build on previous knowledge

e. Identify what you do not understand

3. The student will receive their patient assignment the day of clinical. Complete your clinical
prep by reviewing the patient’s chart. Note MD history and physical; labs & diagnostic tests;
and treatments. Print your MAR for the day from the computer. Note IV fluids/meds.
Complete med cards. List patient meds on attachment. Review your prep with your
nursing instructor.

4. Using the concept map write the patient’s reason for seeking health care, ie Medical
Diagnosis/Surgery in the middle box. Also list key assessments for this patient.

5. Get report on your patient from the staff RN.

6. Complete an assessment of your patient. Be sure to include key assessments. See the
Assessment Guide and fill in the data. Document the assessment in the patient’s record.
Report any abnormalities to your staff nurse and nursing faculty.

7. Analyze the data from the medical record and your nursing assessment. Identify key patient
problems, ie, pain, impaired skin integrity, impaired gas exchange, anxiety, etc. Place each
key problem (nursing diagnosis) in a box on the concept map.

8. In each problem/nursing diagnosis box list supportive data for choosing it: medical history
data; VS; labs; diagnostic tests; pain med frequency; I & O; O2 sats; and your assessment.
(pain, weakness, color, anxiety, etc). Some data may apply to more than one diagnosis/box.

9. Prioritize each nursing diagnosis by numbering with 1 being the highest priority.

10. Analyze the relationships among the nursing diagnosis. Draw lines between nursing
diagnoses that are related. Example: pain and impaired physical mobility = the patient does
not want to move when in pain.
11. From the nursing diagnosis boxes, take the 4 highest priority diagnoses and develop a care
plan with goals/outcomes/nursing interventions/patient responses to interventions/evaluation.
ONLY list interventions that you actually intend to provide your patient! Interventions
include key areas of assessment and monitoring, as well as medications, procedures,
treatments, and patient education. Mark off each intervention as you implement.

12. Post conference: share and discuss your patient’s concept map with your peers. Compare &
contrast patients with the same medical diagnosis, ie, stroke, MI, orthopedic surgery, etc.
Key Problem#: Nursing Diagnosis I do not know what to do with this!
Key Problem #: Nursing Diagnosis

Key Problem #: Nursing Diagnosis

Reason for Seeking Health Care:

Key Problem#: Nursing Diagnosis
Surgery/Medical Diagnosis

Key Nursing Assessments: Key Problem #: Nursing Diagnosis

Key Problem #: Nursing Diagnosis

Key Problem #: Nursing Diagnosis
Key Problem #: Nursing Diagnosis

Concept map
 Assessment Guide

Date: _________ Student: ____________________________ Code Status:

______________
Room #: _______ Diet: ___________ IV (type and rate): ______________ Site appearance
____________
Activity: ________________________ Age: _______ O2_____ Height: _____ Weight:
______
% BMI_________ Nutritional Assessment: __________________________
Alcohol: amount/wk/last used: _____________ Recreational drugs: __________
Allergies_______________
Intake: Oral __________ IV ___________ Other _____ Total________Pathophysiology:

Output: Foley______ Emesis_______ Drains ________

Voided_________ Other _______ Total________

Physical Environment & Patient Safety:

Psychosocial-Spiritual-Cultural: _________________________________________________________________________________
___________________________________________________________________________________________________________
_______________________________________________________________________________________________________
Patient Education/Discharge Plan: ___________________________________________________________________________
_______________________________________________________________________________________________________

Patient Safety Checks:

Chart check: 0800 1000 1200 1400 1600 1800 2000
Safety/Pain/PCA/I.V.: 0700 0900 1100 1300 1500 1700 1900
VS #1: Time: T: P: R: BP: O2: Pain:_______
VS #2: Time: T: P: R: BP: O2: Pain:_______

Questions: Goal for the day, Medical HX, (Psycho-Social-spiritual) Family HX, Surgical HX, allergies, Fall HX, blood reaction
Social (marital, children, occupation/yrs, education, smoking/drinking/drugs/toxins, exercise, sleep (hrs/bedtime), teaching

Assess by systems:
Skin: dryness/itch, color, lesions/bruises/wounds/incisions, turgor, cap refill, nails, temperature, moisture, hair
distribution
Head: hair distribution/texture/quantity, lumps, headache, sinuses, skull size/contour, face symmetry
Eyes: PERRLA, discharge/pain/itch, vision problems, glasses, sclera color, conjunctiva color
Ears: hearing loss, build up/discharge, symmetry, tinnitus, aches
Nose: difficulties breathing –sitting, lying, activity, symmetry/patency, congestion/pain/discharge/tenderness
Mouth: sore throat, dryness, mucosa color/moist, teeth/breath/tongue, lymph nodes, TMJ clicking, difficulty
swallowing
Respiratory: chest symmetry, tenderness/retractions, lung sounds/rhythm, cough, sputum-amount/color/blood, pain
on breathing
Cardiovascular: heart sounds/rhythm, pulses, edema, telemetry
GI: N, V, constipation, diarrhea, normal BM, pain, heartburn, bowel sounds, tenderness/distension/softness,
jaundice, masses
Urinary: frequency, color/amount/odor, nocturia, pain, unusual discharge, bladder distention, tenderness, flank pain
Musculoskeletal: pain, ROM, flex/extension of feet, muscle strength, edema, CMS, activity tolerance
Neurological: numbness, tingling, weakness, tremor, gait, muscle strength, reflexes, memory/cognition, balance,
LOC

Lab Data:

List abnormal labs & give Reflections: what do the results mean for this patient?
Normal range for each

Diagnostic procedures:
_____________________________________________________________________________
_____________________________________________________________________________
__
Treatments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________Medications: instructions:
Have medication cards available for review. List medications & times of administration below. Please
give ordered dosage and normal dosage range with onset/peak/duration of medication. Include patient
teaching and patient response to each medication that you give.

Daily Care Plan: must be completed on the day of care and discussed in post conference.
Be prepared to discuss your rationale for your interventions!

Problem #1/ND:
Goal:

Nursing Interventions Patient responses to

Interventions.
 1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.

Evaluation of progress toward goal:

Problem #2/ND:
Goal:

Nursing Interventions Patient responses to

Interventions.

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.

Evaluation of progress toward goal:

Problem #3/ND:
Goal:

Nursing Interventions Patient responses to

Interventions.

1. 1.
2. 2.
3. 3.
 4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.

Evaluation of progress toward goal:

Problem #4/ND:
Goal:

Nursing Interventions Patient responses to

Interventions.

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
10. 10.

Evaluation of progress toward goal:

Reference:
Schuster, Pamela McHugh. (2008). Concept Mapping (2nd Edition). Philadelphia, F. A. Davis Company