Chapter 3 Concept Mapping: Grouping Clinical Data in a Meaningful Manner

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Chapter 3 Concept Mapping Grouping Clinical
Data in a Meaningful Manner

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Objectives

1. 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 patients response to
   the health problem.
5. List primary assessments associated with the
   medical diagnosis.
6. Label nursing diagnoses.
7. Specify relationship between nursing diagnoses.

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Concept Map

• Assessment data
• (use
  critical-thinking
• skills to
  organize data)
• Nursing diagnoses

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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 diagnosesAnalyze relationships between
   problems (to make meaningful associations between
   segments of the map)

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Scenario

• Age80 y/o
• SexM
• Admission date3/21
• ????Diabetes
• ????New onset diabetes(defined
• above)
• History of hypertention

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Scenario?

• Laboratory data
• blood glucose450
• glycohemoglobin12
• cholesterol240
• urine analysis3 sugar,
• no ketones,
• no protein,
• no WBCs,
• clear yellow

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Scenario?

• Medications
• Humulin N 35U q.A.M., 730 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 ServiceDietary
• ConsultationsDiabetes educator

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Scenario?

• Type of diet1800 ADA
• Intake2200
• Problemsswallowing, chewing, dentures
• (nurses notes)
• Needs assistance with feeding(nurses
  notes)
• Nausea or vomiting(nurses notes)
• Overhydrated or dehydrated(evaluate total
  I/O)
• Belching
• Otherhistory of polyphagia
• Urine Output1800

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Scenario?

• ActivityWeakness
• Physical assessment
• BP138/92
• TPR98.4 77 19
• Height175?
• Weight79?

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Scenario?

• Neurological/Mental Status
• alert and oriented to person, place, time
• Religious preferenceCatholic
• Marital StatusWidower
• OccupationRetired
• Emotional state
• Anxious about giving insulin and following diet

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Step 1-1 Develop a Basic Skeleton Diagram
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Database for Patient with Diabetes

• Step 1-1 Develop a basic skeleton diagram
• Map the framework of propositions
• a. find patients key problems
• concepts
• b. start by centering the medical
  diagnosis

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Step 1-2 Looking Up Information
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• Drugs
• Laboratory and Diagnostic Tests
• Diet
• Medical Diagnoses

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Step 1-3Preventing Falls and Skin Breakdown
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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

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General Data

• X Age over 60
• __History of falls before admission
• __Postoperative/ admitted for operation
• __Smoker

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Physical Condition

• __Dizziness/ imbalance
• __Unsteady gait
• __Diseases/ other problems effecting
• weight-bearing joints
• X Weakness
• __Paresis
• __Seizure disorder

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• __Impairment of vision
• __Impairment of hearing
• __Diarrhea
• X Urinary frequency

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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

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Ambulatory Devices Used

• __Cane
• __Crutches
• __Walker
• __wheelchair
• __Geriatric (geri) chair
• __Braces

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Mental Status

• __Confusion/ disorientation
• __Impaired memory r judgment
• __Inability to understand or follow directions

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Step 2 Analyze and Categorize Data

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Nutrition Polydipsia I 2200 O 1800 Weakness 79?
Elimination I 2200 O 1800 Polyuria
Learning
Newly Diagnosed Diabetes
Anxiety
BP Problems 138/92
Not Sure Skin breakdown?
Figure 3-1
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• Step 3Label DiagnosesAnalyze
• 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.Gordons Functional Health Patterns
• 3.NANDAs Human Response Patterns

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• Figure 3-4-1
• Figure 3-4-2

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Summary

• Psychosocial-cultural assessment
• -- ??Chapter 6
• The purpose of this chapter was to take you
  slowly through the first three step of the
  concept map care planning process.
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