Beyond Nursing Care Plans
58
Concept Care Mapping West Hills College Lemoore
Transcript of Beyond Nursing Care Plans
Concept Care
Mapping
West Hills College Lemoore
DISCLAIMER
Nothing to disclose
Leslie Catron, M.A.E.D, BSN, RN, FAHCEP, CHSE
West Hills College Lemoore, CA
Faculty & Simulation Coordinator
Objectives
Identify the components of the concept care
map including the defining theories of
mapping, critical thinking and clinical
judgment
Demonstrate three ways to use concept care
mapping in the academic and clinical setting
with application specific to simulation
Describe how clinical judgment develops
progressively when maps are used in
simulation scenarios
What is Concept
Care Mapping?
A fluid diagram of
Patient goals
Patient problems
Nursing interventions
Evaluation
THE
FIVE
THINGS!
THERE’S ALWAYS
A THEORY
Education: Novack and Gowin
The Theory of Meaningful Learning
--Linking ideas together--
Education Psychologist: Ausubel
Assimilation Theory
--Identify and integrate
what you already know--
Develops
Clinical
Judgment
A
Critical
Thinking
Tool
A Concept Care Map Is . . .
Concept Care Mapping
Why Bother?
Organize & prioritize patient data
See & analyze relationships in data
Establish priorities for patient care
Concept Care Mapping
Why Bother?
Build on previously obtained
knowledge
Identify what you do not know or
understand!
Enable a holistic view of this
patient’s situation
Begin with the end in mind
Begin with what is known
Build in new knowledge
Formulate questions to
answer
Seek out information &
resources
Works the Nursing Process
Steps in Concept
Care Mapping
Assessment
Nursing Diagnosis
Goals/Outcomes
Interventions
Evaluation
The “Sloppy Copy”
Identify Patient Problems
– From hand-off
– ID on assessment
Assign outcomes
– Measurable goals for THIS
shift
with THIS patient
Steps in Concept
Care Mapping
Components of Nursing Interventions
Assessment of total body system
Monitor laboratory/diagnostic data
Medications
Treatments
Work through each problem
Steps in Concept
Care Mapping
Patient and Family Education
M edications
E nvironment
T reatments
H ealth knowledge of disease
O utpatient/inpatient referrals
or procedures
D iet
Steps in Concept
Care Mapping
View of The Map
Data
Data Data
Data
Data Data
Data
Data
Reason for
Hospitalization
Key Problem
Key Problem
Key Problem
Key Problem
Key Problem
Key Problem
Key Problem
Key Problem
# #
#
# # #
# #
#
Key
Assessments
Problem #1
DX
Predicted Behavioral Outcome Objective
Nursing Interventions Patient Responses to Interventions
Evaluation
Tricks of the Trade
Use different colors...
Be visual...
Write and think
Think and write...
Viewing the Map
The Clear Patient Picture
Key Problem 2: Pain
N.D: Acute Pain r/t spiral fracture of r. femur
aeb FLACC scale.
Goal: Alleviate pain, promote healing
Interventions:
1. Pain scale (FLACC)
2. Acetaminophen 15mg/kg PO q4h PRN.
Reassess w/n 60 min.
3. Long leg splint
4. Assess CMST s/p splint placement
5. Maintain position of comfort (elevate leg)
6. Provide interaction w/caregiver to promote
comfort & sense of security.
7. Pacifier w/50% dextrose dip
Evaluation: Per FLACC scale
Pt.: “Maria Ramirez” DOA: 10/05/09
Age/Sex: 8 mo. ♀ Today’s Wt.: 8 kg
Physician: Dr. Who
Reason for Hospitalization: Parent’s report of
“not acting right”
Primary Medical Diagnosis: Dehydration
Secondary Diagnoses: Increased ICP (2nd to
trauma?). Spiral fracture r. femur
Procedure(s): PIV w/d%LR, Long leg splint
Previous History: No PMH, no meds, normal
pregnancy & delivery @ 38 wks.
Allergies: NKA/NKDA
Language Spoken: English
Focus Assessments: Bulging fontanel & seizure
(evidence of ICP), Dry mucous membranes &
report of decreased I&O (evidence of
dehyrdration).
Pt’s Goal: Relief of pain & thirst
Key Problem 4: Unsafe living conditions?
Possible non-accidental trauma.
N.D: Risk for further injury r/t unsafe home
environment aeb spiral fracture. Possible brain
damage w/o adequate explanation
Goal: No further injury. Guilty party behind
bars
Interventions:
1. RN gather background info on family
situation. Talk to each parent separately.
2. Social Work consult.
3. MD place child on temp CPS hold
4. Alert CPS
Evaluation: (See Goal above)
Key Problem 3: Dehydration
N.D: Less than adequate nutrition/hydration
aeb report of decreased I&O & dry mucous
membranes.
Goal: Appropriate output (urine, tears, etc) &
moist mucus membranes, cap refill, etc.
Interventions:
1. Accurate I&O
2. Daily weight
3. CBC/BMP (monitor fluid/lyte balance)
4. IV D5LR per rehydration protocol
5. Advise MD of weight below average
Evaluation: (See Goal above)
Key Problem 1: Decreased LOC
N.D.: Decreased intracranial adaptive capacity
aeb irritability, decreased LOC, seizure activity
& bulging fontanel
Goal: Return to LOC appropriate to age. No
s/sx of distress. No seizures.
Interventions
1. CBC/BMP/blood/ruine C&S
(fluid/lyte imbal? Inflamm? Infxn?)
2. IV D5LR rehydration per protocol
3. Place on moniotor/con. Pulse ox.
4. Hourly neuro check x4
5. Head CT
6 Notify MD of seizure & bulging fontanel
Evaluation: (See Goal above)
Concept Care Map
Name: Tom Johnson
Date: 10/06/09 (sim lab)
Instructor: L. Catron
Clinical Rotation: Pediatrics
Let’s Map!
Use mapping for
ANY problem solving
THE “PROBLEM”
We’re Having a Party!
Mapping
Topic:
Party
Date & Time
Related Items
Where to go
Who to invite
Related Items
Related Items
Mapping
Next steps
What can be more specific?
What are the needs?
Any new ideas to add?
Let’s Map!
Topic
Party
Date & Time
Where to go
Who to invite
Local campus
Usual friends
Workday or weekend
Weather permitting
A.M. or P.M.
Neighboring town Palm Springs
New “blood” Spouses
Let’s Map!
Thinking through the process
What things relate to other things?
What things influence the others?
What new things can be added?
Let’s Map!
Topic
Party
Date & Time
Where to go
Who to invite
Local campus
Usual friends
Workday or weekend
Weather permitting A.M. or P.M.
Neighboring town
Palm Springs
New “blood” Spouses
Mapping a
Real Patient
MAP!
Milca
1
Key Problem # N.D Goal Interventions 1. 2. 3. 4. 5. Evaluation to Goal
Pt. DOA Age Today’s Wt. kg Physician Reason for Hospitalization Primary Medical Diagnosis Secondary Diagnoses Procedure(s Previous History Allergies Language Spoken Observed Assessments Patient’s Goal
Key Problem # N.D Goal Interventions 1. 2. 3. 4. 5. Evaluation to Goal
Key Problem # N.D Goal Interventions 1 2. 3. 4. 5. Evaluation to Goal
Key Problem # N.D Goal Interventions 1 2. 3. 4. 5. Evaluation to Goal
Patient Concept Care Map Name Date Instructor
MAP!
Milca 10 years old
Osteogenesis Imperfecta
Dr. Geradi
No known allergies
Admitted for cast removal to Fracture of the left arm
Multiple hospitalizations for fractures since 4 mths. of age,
Dr. states admissions at least “10 each year.”
She states her Pain today 4/10
She states that pain can be 107/10
Lives with mother and father, 2 siblings
Mobility: motorized wheelchair, can move self out and onto
chair and bed
Activities of daily living: able to perform personal care,
mainstreamed into 4th grade, teacher states “treated
like all the other children.”
Mom tells that before Milca was first diagnosed there was
suspicion of child abuse because she had broken ribs
and a broken leg . She had to speak with child
protective services and she was very uncomfortable
being accused.
MAP!
Map the “Sloppy Copy”
Place the patient at the
center of care
At the center of the map
what data matters today?
ID the patient problems
as heard
MAP!
Decide the 12-hour
goals for THIS patient
What can be
accomplished?
Will this move the patient
toward discharge?
Does it work with the total
plan of care?
MAP!
ID the Disease Process
with Nursing Interventions
Ask Yourself:
– “What does it affect?”
– “So what?”
– “Why?”
THINK it through
“Brushing up on Learning”
Is assessment data complete and accurate?
Do nursing problems relate to symptoms?
Are there potential complications of symptoms ID?
Are the nursing goals clear?
Is the patient’s goal included?
“Brushing up on Learning”
Are the nursing actions
appropriate?
What effect will this nursing
intervention have on this
patient’s outcome for this
shift?
What was your thinking in
making your connections?
“Brushing up on Learning”
What teaching was
included? Discharge
planning?
What wasn’t known that
needed to be find out?
What resources were
needed?
“Brushing up on Learning”
Could there be measurable
evaluation to the goals set?
What was gained from
writing THIS map?
What was left off this
map? Why?
Care for the Patient
Evaluate against the set goals
Debriefing the Results
Clinical Judgment
Clinical Reasoning
Critical Thinking
Evaluation
Student – New Graduate – Staff Member
Evaluating Learning
Qualitative
Observed evidence of improved
care planning, competency and
critical thinking
– Observation
– Survey
Quantitative
Scored evidence of improved ability to plan, prioritize,
critically think and make clinical judgments
– Rubric
Name ________________________________________________Date _____________
Simulation Facilitator _Leslie Catron_______Patient ________ SCORE___________
4 – Exceeds expectations defined for the care map – above the minimum requirements
3 – Meets expectations defined for the care map – at the minimum requirements
2 – Below expectations – needs to improve – did not meet the minimum requirements
1 – Does not meet expectations – some effort was made
FINAL POSSIBLE TOTAL SCORES: 60 exceeds expectations for the care map
45 meets expectations for the care map
West Hills College Concept Care Map - SIMULATION
CHEXBRICK
Meets Expectations
Step One: Date Collection and Data Assessment
Comments
1.
2. 3 3.
Identifies physiological & psychological Problems
☐ 1
☐ 2
☐ 3
☐ 4
3 4.
Medications categorized in correct boxes
☐ 1
☐ 2
☐ 3
☐ 4
3
Treatments & Diagnostic tests categorized in correct boxes
☐ 1
☐ 2
☐ 3
☐ 4
3
Prioritizes problems correctly
☐ 1
☐ 2
☐ 3
☐ 4
3
Key assessments identified (Center Box)
☐ 1
☐ 2
☐ 3
☐ 4
Total Points
Meets expectations Minimum 3 identified patient problems
1 - one must be psychosocial
Meets expectations Medications listed correctly under the correct
problem: dose, time and route, reason
Meets expectations Minimum 3 - Note all items to be monitored,
observed, and reviewed abnormal findings that require follow-up based on pt. condition
Meets expectations Prioritize the problem to be addressed first.
Each problem numbered in order of priority to be addressed and/or assessed
Meets expectations “Peek-at-the-door” assessment of the patient as
related to the problems What would you see walking by the room to
assess the patient’s condition?
3
Correctly labels nursing diagnoses (NANDA)
☐ 1
☐ 2
☐ 3
☐ 4
Meets Expectations
Step Two: Establishes Measurable Outcomes
Comments
3
List goals/outcomes for each problem identified – must be measurable (Physical and Psychosocial)
☐ 1
☐ 2
☐ 3
☐ 4
3
List goals/outcomes for the patient (Center Square) – what does the patient what to have/do/see in this simulation?
☐ 1
☐ 2
☐ 3
☐ 4
Meets expectations Minimum 3 – one for each problem
Correctly identified
Meets expectations Problems have a measurable goal for this
patient in this simulation Can be met at the end of this simulation or to
some extent & moves the pt/fm. toward dischg. goals.
Meets expectations – Patient Satisfaction Written in the “patient’s” expected own words in answer to the question “What would you like to
see happen as we work together today?”
Step Three: Establishes Interventions for Care
Comments
1. 2. 3 3. 3 4. 3 5.
Lists age appropriate, safe nursing care interventions to attain objectives, includes assessments to be performed, communication and physiological care. Includes patient and family participation in care and patient and family education
☐ 1
3 points - only 1 problem with 3 interventions and patient/family education to this problem
☐ 2
6 points - two problems with 3 interventions each and patient/family education to this problem
☐ 3
9 points - three problems with 3 interventions each and patient/family education to this problem
☐ 4
12 points - four problems with 3 interventions each and patient/family education to this problem
Meets expectations Minimum 3 nursing interventions under each
patient problem Includes patient/family education identified and
specific to this patient What will be taught toTHIS patient/family?
3
Identifies resources available and state When and how to use them
☐ 1
☐ 2
☐ 3
☐ 4
Meets Expectations
Step Four: Evaluates Patient Response to Care
Comments
3
Evaluates patient responses to nursing interventions for all patient problems
identified
☐ 1
☐ 2
☐ 3
☐ 4
Meets expectations - Minimum 3 patient problems with at least one identified
Interdisciplinary Team Resource that can participate in the patient care
Meets expectations - Patient problems have a mini evaluation done at end of the simulation
Evaluate against the goal set at the beginning of simulation with the nursing interventions set to
meet the goal. Was the goal met?
If it was how? If it wasn’t why not?
3 3
This is done on the back of the Care Map
Evaluates patient physical behavioral Responses to nursing interventions for at
least 1 Priority physical nursing diagnosis
1 Priority psychosocial nursing diagnosis
☐ 1
Attempt at one evaluation – not complete and/or no critical thinking evaluation of work evident
☐ 2
Attempt at two evaluations – not complete and/or no critical thinking evaluation of work evident
☐ 3
6 points – 1 evaluation completed and/or incomplete 2 evaluations – some evidence of critical thinking
☐ 4
8 points – 2 evaluations completed with clear evidence of critical thinking and clinical reasoning
Meets expectations Minimum 2 – Complete a reflective evaluation for two patient problems –
one physical, one psychosocial at the end of the simulation.
Evaluate each nursing intervention – Did each nursing interventions
move the patient to the goal? If not why? Complete an overall evaluation of care given: Were all the interventions met? If not why?
Were there interventions left out? Why? Could other interventions have been included? Why?
Answer: Overall, did the patient improve on your shift and move closer to discharge?
Evaluation - Qualitative
Observe changes in how
the learner writes
concept maps
Ask the learner what
needs to be added or
removed to improve the
map
Promote open
discussion about
mapping with all learners
Evaluation - Quantitative
The Rubric provides
A score or grade
Expected outcome for
each area of the map
A benchmark for
improvement
Evaluation – Peer to Peer
Opportunity for personal reflection into
practice
Improves interdisciplinary communication
skills
Allows for an alternative perspective into
patient care based on feedback
Key Problem: Nutrition x2 days
N.D: Imbalanced nutrition, less than body
requirements r/t head trauma
Goal: Pt will maintain adequate nutrition by date of
discharge
Interventions:
1. Maintain clear liquid diet and advance as
tolerated
2. Admin LR at maintenance rate for weight @ PIV,
SL if PO intake OK
3. Notify physician ASAP if PT is not taking PO or
vomiting
4. Daily weight check for s/sx dehydration/over-
hydration, check labs, strict I&O, UA
5. Encourage parental involvement to increase
nutrition by consoling, breast feeding (if applicable).
Evaluation: Pt maintaining adequate hydration of
clear liquids, IV fluids, 2ml./kg/hr = 14ml/.hr,
328ml/24hr. Skin turgor elastic, mucus membranes
moist, 0 wt change from admit date.
Pt. M.R. DOA: 10/06/09
Age: 8 months Today’s Wt. 7 : kg
Physician: Shephard, Robbins
Reason for Hospitalization: Fussy, not eating
well 2x days
Primary Medical Diagnosis: Spiral fx R femur
Secondary Diagnoses: Seizure, r/o non-
traumatic injury, possible abuse
Procedure(s): x ray R leg, CT scan, neuro
checks Q1hr, social work/CPS visit
Previous History: None contributory (normal
vaginal birth @ 40 weeks)
Allergies: NKA
Language Spoken: English
Focus Assessments: Neuro/possible ICP,
musculo-skeletal
Pt’s Goal: Mother’s goal is to “Bring baby
home as soon as possible.”
Key Problem: Fussy and irritable with inconsolable
crying
N.D: Increased pain r/t head trauma as evidenced
by crying, fussiness, seizures
Goal: Pt will remain non-fussy and free of pain by
date of discharge
Interventions:
1, Admin acetaminophen 215mg (15mg/kg) PO/PR
Q4hr for temp>101.5; IBU 70mg (10mg/kg) PO
Q6hr PRN pain/temp >101.5 for sx unrelieved by
acetamin.
2. Ondanstetron 0.7mg (o.1mg/kg) IV Q6hr PRN
N/V
3. Hold baby to console Q1hr PRN crying,
irritability, assess pain Q1hr
4. Stress/noise/distractions; create calm, relaxing
environment
5. CPS/social work to address SBS with parents,
arrange custody/care
Evaluation: GCS of 15 and stable neuro status;
FLACC scale of 0-5 maintained, pt able to sleep and
eat without discomfort.
Key Problem: Spiral fx R leg
N.D: Pain r/t fx R leg as evidenced by pt crying, not
eating, fussy/inconsolable
Goal: Pt will remain non-fussy and free of signs of
pain by date of discharge
Interventions:
1. Evaluate pain using FLACC score Q1hr; keep
score 0-2
2. Console baby with non-medication techniques
(distraction, soothing)
3. Keep affected R leg femur fx stabilized with
correct position to discomfort
4. Admin acetaminophen 215mg PO/PR Q4hr pain;
admin IBU 70mg PO/PR Q6hr for pain not relieved
with acetaminophen
5. Teach parents cast care, mobilization techniques,
pain cues.
Evaluation: Pt had FLACC score of 0-2 with mild
crying. Pt was consolable with distraction, soothing
techniques and meds.
Key Problem: Seizure r/t head trauma (SBS)
N.D: Ineffective airway r/t seizure as evidenced
by respiratory arrest
Goal: Pt will maintain a clear and patent
airway by date of discharge
Interventions:
1. Monitor airway, oxygenation status: have O2
mask & monitor at bedside
2. Implement seizure precautions: remove soft
objects from crib, put seizure pads on sides of
crib
3. Monitor v/s and perform neuro checks Qhr,
watch for s/sx ICP
4. Admin anti-seizure/ICP meds if ordered,
teach parents seizure care
5. Monitor labs, check IVF to labs, monitor
I&O, daily weight
Evaluation: Pt maintaining 0 seizure status,
s/sx of ICP. Airway patient with pt
exhibiting 0 s/sx respiratory distress.
Concept Care Map
Name: Denise Lee
Date: 10/06/09
Instructor: L. Catron
Clinical Rotation: Peds
Outcomes/Goals
Patient Stability
Medical Care Plan
Nursing Care Plan
Reflection on Lesson Learned
• Case Study – Problem Based Learning
• Scenario: Objectives Met
• ADPIE
• CONCEPT MAP = Individualized Plan of
Care
Reflection on Lesson Learned
• Setting-Situation-Questions
Reveals the Progress of Thinking
• Peer & Instructor Feedback
• Evidence of Critical Thinking, Clinical
Reasoning & Clinical Judgment
Assimilation and
Integration for Safe
Patient Care
Previous knowledge
gained through
experience and study
New Knowledge
gained through
resources, experience
and reflection on practice
New Practice
