Care Plan/Concept Map

Workshop

Nursing Care Plans/Concept

Maps
Utilize the Nursing Process to construct

an individualized plan of care for a

patient based on a critical analysis of
patient assessment data

Nursing Process: Systematic method of

giving humanistic care that focuses on

achieving outcomes in a cost effective
manner.

Nursing Care Plans

Written guidelines for client care
Organized so nurse can quickly identify

nursing actions to be delivered

Coordinates resources for care
Enhances the continuity of care
Organizes information for change of
shift report

The Nursing Process is a

Systematic Five Step
Process

Assessment
Diagnosis
Planning
Implementation
Evaluation

Why Use the Nursing Process

for Care Plans
Requirement set forth by national

practice standards (ANA, TJC)

Basis for NCLEX exams
Based on principles and rules that
promote critical thinking in nursing

Putting it All Together

Assessment: The first step in determining a

patientss health status.

Gather information, put pieces of the health
puzzle together.
Entire plan is based on the data you collect,
data needs to be complete and accurate
Collect, verify, and organize data, identify
patterns, report and record the data.
Report significant abnormalities immediately.

Case Scenario
Mr. Jones complains his throat and mouth

are dry. He is allowed fluids, but has had

almost nothing to drink all evening. He
tells you he would like to drink, but
doesnt like water, especially the warm
water in the pitcher. He also hates to
bother the nurse. The nurse notes his
oral mucosa is dry and cracked and his
urine output for the last shift is low.

Assessment
First step in determining health status
Gather information
Gather all the puzzle pieces to put

together a clear picture of health status

Entire plan is based on data collected
Data needs to be complete and
accurate, make sense of patterns

5 Activities Needed to Perform

a Systematic Assessment
Collect data
Verify data
Organize data
Identify Patterns
Report & Record data

Comprehensive Data
Collection
Begins before you actually see the patient

(Nurse report from ER, Chart reviews)

Continues with admission interview and
physical assessment once you meet patient.
Other information resources include: family,
significant others, nursing records, old
medical records, diagnostic studies, relevant
nursing literature.
Consider age, growth & development

Whats Important Data?

Name, age, gender, admitting diagnosis
Medical/surgical history, chronic illnesses
Advanced Directives
Laboratory Data/Diagnostic tests
Medications
Allergies
Support Services
Psychosocial/Cultural Assessment
Emotional state
Comprehensive Physical Assessment

Comprehensive Physical
Assessment
Vital signs
Height & weight
Review of systems (neurological/mental

status, musculoskeletal, cardiovascular,

respiratory, GI, GU, skin and wounds.
Standardized risk assessments:
Pressure ulcers, falls, DVT

Organizing Assessment
Data
Cluster data into groups according to a

nursing or medical model (Maslows Basic

Human Needs Model)
Clustering data helps maintain a nursing
focus, allows patterns to be recognized
Cluster by body system or need deficit
Helps to identify nursing diagnosis pertinent
to your client
Example: All information gathered regarding
nutritional status may help to identify
nutritional alterations

Diagnosis
AssessmentCritical analysis of data

Diagnosis or Problem Identification

Laws & standards continue to change to
reflect how nursing practice is growing
(APN role)
Novice nurse responsible for recognizing
health problems, anticipating
complications, initiating actions to
ensure appropriate and timely treatment.

Identifying Nursing
Diagnosis
Common language for nurses
A clinical judgment about an individual, family

or community response to an actual or

potential health problem or life process,
Nursing diagnosis provide a basis for
selection of nursing interventions so that
goals and outcomes can be achieved
NANDA list of acceptable diagnoses, updated
every 2 years.

Diagnostic Reasoning
Apply critical thinking to problem

identification
Requires knowledge, skill, and
experience
Big Picture

Fundamental Principles of
Diagnostic Reasoning
Recognize diagnoses
Keep an open mind
Back up diagnosis with evidence
Intuition is a valuable tool for problem

identification
Independent thinker
Know your qualifications & limitations

Nursing Diagnosis
Actual or Potential problems identified
Actual: actual evidence of

signs/symptoms of diagnosis exist.

(Fluid Volume Deficit)
Potential/Risk for Diagnosis: clients
data base contains risk factors of
diagnosis, but no true evidence (Risk
for altered skin integrity)

Writing a Nursing Diagnosis

Actual Problems: Problem (NANDA

label) & Etiology & Supporting Signs

and Symptoms
Impaired Communication related to
language barrier as evidenced by
inability to speak English

Writing a Nursing Diagnosis

Potential or Risk Problems: Problem

(NANDA label) & etiology or problem &

risk factors with related to statement
linking problem to risk factors.
Risk for Impaired skin integrity related
to obesity, excessive diaphoresis, and
immobility.

Writing A Nursing Diagnosis

Use accepted qualifying terms (Altered,

Decreased, Increased, Impaired)

Dont use Medical Diagnosis (Altered
Nutritional Status related to Cancer)
Dont state 2 separate problems in one
diagnosis
Refer to NANDA list in a nursing text
books

Planning: 4 Part Process

Set your priorities of care, what needs to be

done first, what can wait.

Apply Nursing Standards, Nurse Practice Act,
National practice guidelines, hospital policy
and procedure manuals.
Identify your goals & outcomes, derive them
from nursing diagnosis/problem.
Determine interventions, based on goals.
Record the plan (care plan/concept map)

Planning
Risk for Impaired skin integrity related to

immobility
Now restate the first clause in a statement
that describes improvement, control or
absence of problem
The patient will have no signs of skin
breakdown during hospital stay.
Outcome needs to be time related. ( state
time period to achieve goal)

Short Term vs. Long Term

Goals
Short term goal can be achieved in a

reasonable amount of time ( few hours to few

days)
Long term goals may take weeks/months to
be achieved
Client will ambulate down the hall within 2
days.
Client will walk the length of the hallway
independently by the end of 2 weeks

Achieving Goals/Outcomes
Be realistic in setting goals. (look at overall

health state, growth & development level,

prognosis)
Set goals mutually with client
Goals should be measurable, use
measurable, observable verbs
Identify one behavior per outcome
When indicated use short-term vs. long tern
goals

Determining Interventions
Nursing interventions are actions performed

by nurse to reach goal or outcome

Monitor health status
Minimize client risks
Direct Care Intervention: Direct action
performed to client (inserting foley catheter)
Indirect Care Intervention: actions performed
away from client ( looking at lab results)

Determining Interventions
Interventions will be collaborative, combining

nursing actions and physician orders.

Ineffective Airway Clearance related to
incisional pain
Nursing Actions: Ascultate breath sounds
every four hours, Assist with coughing and
deep breathing every hour etc.
Physician orders: pain medication, activity
orders

Implementation
Putting your plan into action
Set priorities after report
Assess and reassess
Perform interventions
Chart client responses
Give report to next shift

Implementation of Nursing
Interventions
Describes a category of nursing

behaviors in which the actions

necessary for achieving the goals and
outcomes are initiated and completed
Action taken by nurse

Types of Nursing
Interventions
Protocols: Written plan specifying the

procedures to be followed during care of

a client with a select clinical condition or
situation
Standing Orders: Document containing
orders for the conduct of routine
therapies, monitoring guidelines, and/or
diagnostic procedure for specific condition

Implementation Process
involves:
Reassessing the client
Reviewing and revising the existing

care plan
Organizing resources and care delivery

(equipment, personnel, environment)

Evaluation
Evaluation of individual plan of care includes

determining outcome achievement

Identify variables/factors affecting outcome
achievement
Decide where to continue/modify/terminate plan
Continue/modify/terminate plan based on
whether outcome has been met (partially or
completely)
Ongoing assessment of QI

Evaluation
Step of the nursing process that

measures the clients response to

nursing actions and the clients progress
toward achieving goals
Data collected on an on-going basis
Supports the basis of the usefulness and
effectiveness of nursing practice
Involves measurement of Quality of Care

Evaluation of Goal
Achievement
Measures and Sources: Assessment

skills and techniques

As goals are evaluated, adjustments of
the care plan are made
If the goal was met, that part of the care
plan is discontinued
Redefines priorities

Concept Map Care Plans

Innovative approach to planning & organizing

nursing care.
Essentially a diagram of patient problems and
interventions
Ideas about patient problems and interventions
are the concepts to be diagrammed.
Enhances critical thinking and clinical
reasoning
Used to organize patient data, analyze
relationships, establish priorities

Theoretical Basis of
Concept Maps
Roots in education and psychology
Also known as mind maps, cognitive

maps
Concept mapping requires critical
thinking
New knowledge is built on preexisting
knowledge, new concepts are
integrated by identifying relationships

Steps in Concept Map Care

Planning
Develop a Basic Skeleton Diagram
Analyze and Catagorize Data
Analyze Nursing Diagnoses

Relationships
Identifying Goals, Outcomes, &
Interventions
Evaluate patient responses