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case

create a concept map using the case study in the power point and the concept map outline 

NUR 357 Concept Map Guidelines

Concept Map Description:

A concept map is a picture or chart that illustrates the relationships between the patient’s medical diagnosis(es), the symptoms he/she is demonstrating, the patient lab values, the medications he/she is on, and the clinical judgment model.

The concept map be seen as a type of “puzzle” with all the components making up the pieces that complete the total picture. The concept map also is useful in helping you to identify priorities in nursing care by considering the whole picture of the patient’s condition and vital to clinical decision making.

STEPS TO COMPLETE THE CONCEPT MAP:

1.
Recognize Cues: Review your patient’s History and Physical. Identify the current medical diagnoses, chronic health problems. This is often the reason for seeking health care (often a medical diagnosis). Create a Situation and Background to start the map.

2. Recognizing Cues: what are the correlating patient signs and symptoms, and include results of labs and other diagnostic tests that have been done. (Blood tests, pulmonary function tests, x-rays, EKG’s, etc.)

CJ Tasks

Prompts/Considerations


Recognizing Cues:

Which patient information is relevant: Consider signs and symptoms, lab work, patient statements,

H & P, and others. Consider subjective and objective data.

• Which cues were relevant? Irrelevant?

• What is occurring in the environment?

• Which laboratory data are significant?

• What is significant in the patient’s history?

• What is the immediate concern?

• What factors may exist related to the abnormal data?

3. Analyze cues: Linking of recognized cues to the client’s clinical presentation and establishing probable client needs, concerns, and problems.

CJ Tasks

Prompts/Considerations



Analyze cues:

• Recognize patterns and cluster the cues from above together.

• Link cues. Recognize patterns. Name this as an issue or descriptor of your cluster

• Determine what is concerning. Name it. M
inimum of 3 clusters/concerns

• Determine if additional information is needed.

How do the data link to other information?

What patterns do you recognize?

Which patient conditions are consistent with the cues?

What cues are a cause for concern?

What other information would help to establish the significance of a cue?

What else do you need to know to generate a hypothesis?

4. Prioritize hypotheses: Identify all problems (medical/nursing diagnoses) that apply and correlate on the map with the data that supports the diagnosis. Identify and rank the medical/nursing diagnoses in order of priority.


CJ Tasks

Prompts/Considerations


Prioritize hypotheses: minimum of 3

• Cluster information.

• Narrow possibilities.

• Determine order of priorities.

• Determine risk for action or inaction.

• Provide evidence for hypothesis

What conclusions can you make?

What explanations are most likely?

What other conclusions could be possible?

Which cues indicate the most serious risk for a health problem?

Which cues indicate action is required?

What is the priority order for safe and effective care?

5. Address the pathophysiology and etiology of presenting problem (reason why patient is admitted/primary complaint)

For each presenting problem, thorough review of the Pathophysiology at cellular level, shows understanding of medical diagnosis and comorbidities (identifies most risk factors present) and identifies etiology based on the specific patient’s conditions.

6. Generate Solutions: Identify the plan of action(goal) for each problem (medical/nursing problems).


CJ Tasks

Prompts/Considerations


Generate Solutions:

minimum of 2 SMART goals/solutions for each hypothesis

establish the goals to remedy problems what would be a fix, prevention, or maintenance of desired level.

· Determine desired outcomes.

· Determine the best solution based on evidence.

· Determine what resources are needed (e.g., people, equipment, medications)

· Each goal follows the SMART format (Planning- specific, measurable, attainable, realistic/relevant,

time-restricted)

What are the desirable outcomes?

What should be avoided?

What solution will be most helpful for this client?

What is the priority to address each problem , fix over maintain or manage symptoms?

• What evidence did you use to choose this solution?

• What are the risks for choosing or not choosing this solution?

What is a realistic timeframe to accomplish?

7. Take Actions: Implement the plan: Identify the nursing actions (interventions) and rationale to address each problem (medical/nursing diagnosis)


CJ Tasks

Prompts/Considerations


TAKE ACTION Minimum of 2 actions/interventions with rationale for each SMART Goal/solution

•Implement plan.

• Perform skill/procedure.

• Administer medication.

• Collaborate with the team.

• Teach patients/families/staff/team.

• Demonstrate ethical/legal behavior

· What interventions can achieve the outcomes?

· How should the intervention or combination of interventions be

· performed, requested, communicated, taught, etc?

· What (e.g., people, equipment, medications) is needed to take this action?

· What’s the rationale for each intervention as it relates to a goal/fix connect to path and or goal?

· Are there contraindications to this action?

· What will you do if patient refuses the medication or treatment?

· When would the interventions be or not carried out?

· What will you do if there are not sufficient resources or team members?

· What are the priority interventions? (Mark with asterisk)

· Is there particular order in which to carry out the interventions?

8. Evaluate Outcomes: identify what criteria the patient will obtain to attain the goal. Determine the result. Evaluate all SMART goals/solutions.

CJ Tasks

Prompts/Considerations


Evaluate outcomes evaluates all SAMRT goals/solutions.

· Identifies the SMART goal being evaluated

· Links to nursing action.

· Was goal Met or Not Met.

· How was the goal met.

· If not met, the revision includes what interventions didn’t work and what should be done instead in the future.

Results of taking actions:

Did the patient’s care outlook or status improve?

What signs point to improving/declining/unchanged status?

· What indicates your action was/was not effective?

· If the actions are effective, not improving indicate what data indicates a further complication?

· What action is need next/ what revisions need to be made?

· What (e.g., medications, labs, or treatments) do you need to continue monitoring?

· What would be a priority to report to the healthcare provider?

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