bsn concept mapping

Concept Mapping...for the slightly confused

Diana Benton RN - 2010

...focused on a holistic nursing view of the patient, rather than a disease model

What’s a concept map anyway?

...an innovative approach to planning and organizing nursing care

...guides the student’s focus so he or she can learn to analyze relationships in clinical data and to prioritize the

needs of a specific client

...helps with organizing the problems and care of patients in a logical

fashion

For the student

... a visual representation of the critical thinking ability of inexperienced nurses

For the instructor

A description we’ll expand upon is...

5. evaluation

1. assessment2. nursing diagnosis3. goal4. intervention

A concept map isa diagram

of the sequential steps of the nursing process.

Let’s get started...

This is D.J. - he fractured his right femur when he jumped off the roof. You’d think a 42 year old

guy woulda known better!

Although there are many different ways to make a concept

maplet’s do it my way and...

...start with a circle in the center of the paper identifying the patient.

D.J.42 year old

male

Admitting dx: Fx Right

Femur

Then, to plan the patient’s care, you’ll utilize...

the nursing process

ssess the

patient

and gather subjective and objective data

To begin....

Subjective Assessment

Data(information that only the client

feels and can describe)

MY LEG HURTS !

When I sit up

I get dizzy

headed.

I feel awful.

I’m depressed.

I feel lik

e I’m

gonna throw up.

Sympto

ms

Objective Assessment

Data (observable or

measurable facts)Vital Signs

BP 150/68 - Pulse 96

Weight200#

Moaning

Pallor

SignsConcurrent Health Problems

Pertinent Labsand

Diagnostic Tests

Buck’s t

raction (R

) leg

Xray: (R) femoral neck fracture

Make 2 more circles.It will help you remember to check D.J.’s chart for additional objective data and besides, you could use the extra space!

Let’s see how this assessment data looks when added to

your concept map

D.J.42 year old male

Admitting dx: Fx Right Femur

Subjective Assessment Data

Objective Assessment Data Pertinent Labs

and Diagnostic Tests

Concurrent Health

ProblemsNone

Needs Further Assessment

c/oPain (R)

leg

BP = 150/68

Pulse = 98Xray:

(R) femoral neck fracture

If you realize you need to get more information .. make a note

here to remind yourself

Buck’s traction (R) leg

Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

iagnosis

ursing

Now to come up with a...

Look at the assessment data.

Identify patterns of related responses to an actual or potential health problem.

Xray: (R) femoral

neck fracture

BP = 150/68

Pulse = 98Moaning

c/oPain (R) leg

Based on the problem identified, chose an appropriate nursing

diagnosis from the NANDA list.

ACUTE

PAIN

D.J.42 year old

male


Femur



Data Pertinent Labs


Concurrent Health

Problems

None

Needs Further Assessmentc/o

Pain (R) leg

BP = 150/68

Pulse = 98Xray:



Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAIN

Add this nursing diagnosis to your concept map.

You must be able to show the relationship between each nursing diagnosis you chose and the assessment data upon which it was based.

As you add more diagnoses...

... your map can begin to look like a confusing mess.

Skip the lines.

ACUTE PAIN

Another Diagnosis

Another Diagnosis

Instead... use a 3 part nursing diagnosis that includes:

Nursing Diagnosis: ACUTE PAIN

R/T (R) femoral neck fracture

Diagnosis

Cause“related to”

Indicators“as evidenced

by”

AEB c/o Pain (R) leg / moaning / BP = 150/68 / pulse 98





Data Pertinent Labs


Concurrent Health

Problems

None


Pain (R) leg

BP = 150/68

Pulse = 98Xray:



Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

You gotta admit...that

looks a lot better!

When added to your concept map it should look like this:

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fracture

AEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

After you have decided on a nursing diagnosis, set a patient-focused...

oal

specific measurable

attainable

so you will be able to determine if desired outcomes of care are achieved

realistic timely

ACUTE PAIN

So what’s gonna be your patient-focused goal

The will...

he just broke his leg...it’s gonna hurt!

...have no pain

...report pain controlled at a tolerable level this is more realistic but...

How are you gonna determine if the pain is tolerable

“reports pain levels of < 5 on a scale of 0 to 10

within the next 24 hours”

specific

measurable

attainable realistic timely

Now that’s a smart goal

D.J.42 year old

male


Femur



Data Pertinent Labs


Concurrent Health

Problems

None


Pain (R) leg

BP = 150/68

Pulse = 98Xray:



Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAINR/T (R) femoral neck fractureAEB c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

Put this goal on your concept map.

Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours

Now you need to decide on nursing...

nterventions

that, when implemented, will enable the patient to achieve the stated goal

Explain 0 to 10 pain scale / need not wait until pain is severe

Maintain Buck’s traction to muscle spasms

Provide periods of uninterrupted rest

Refresh ice to right femur prn

Administer ordered pain meds prn / assess pain relief 30 min. after medicating

I know some!

D.J.42 year old

male


Femur



Data Pertinent Labs


Concurrent Health

Problems

None


Pain (R) leg

BP = 150/68

Pulse = 98 Xray: (R) femoral

neck fracture


Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Add your interventions.

Interventions:

Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Buck’s traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.


Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours




Pertinent Labs and Diagnostic Tests

Concurrent Health Problems

None


c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral neck

fracture


Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Following the same sequence of steps, you can develop additional nursing diagnoses along with goals and interventions.

Objective Assessment Data

Nursing Diagnosis:

Interventions:

Goal:

Nursing Diagnosis:

Goal:

Interventions:


Goal:The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Interventions:


At this point...

prioritize the needs of your patient based on

Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs

Self-actualization

Esteemfeeling of accomplishment

Love and belongingintimate relationships and acceptance

Safetyfeel safe and avoid danger

Physiological needs basic to human survival oxygen, water, food, shelter, and sleep







None


c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral neck

fracture


Moaning

c/o nausea

“depressed”

Pallor

“dizzy”

Nursing Diagnosis: ACUTE PAINNumber each nursing

diagnosis on your concept map in order of priority.



Nursing Diagnosis:

Interventions:

Goal:

Nursing Diagnosis:

Goal:

Interventions:

1

2

3

Interventions:


valuation

Lastly, do an...

of the effectiveness of the interventions in relation to goal set

if goal is not being met, what changes do you need to make?






Data


Concurrent Health

Problems

None


c/oPain (R) leg

BP = 150/68

Pulse = 98

Xray: (R) femoral

neck fracture


Moaning

c/o nausea

“depressed”

Pallor

“dizzy”


Interventions:


Evaluation:Goal met – patient reports pain controlled between levels 1 - 4 during past 24 hours

1

Yea, you just made a...

... concept map!Wasn’t that easy?

Client





Nursing Diagnosis: ___________________________________ Goals: ___________________________________ Interventions:

Evaluation

Nursing Diagnosis: ____________________________________ Goals: ____________________________________ Interventions:

Evaluation

Nursing Diagnosis: _____________________________________ Goals: _____________________________________ Interventions

Evaluation


CONCEPT MAP

bsn concept mapping

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