Deanna B. Hiott MSN,RN

• Are not as abstract as

they seem

• The concept map is a

visual of all your

patient’s problems.

• The care plan is just

your plan of care for

your patient!

• Who is your patient?

• What is the medical diagnosis?

• What are the patient’s presenting symptoms?

• What does the assessment ‘say’ about the patient?

• The review of systems?

• The vital signs?

• Any social, cultural, psychological or spiritual concerns…

• The concept map

• The care map

• The concept care map

• Yeah, that thing…

• They promote critical

analysis

• They help clarify

nursing diagnoses

• It takes the guesswork

out of the picture

• Based on the patient’s reason for seeking care.

• Based on the assessment and vital signs.

• Based on the medical diagnosis, labs, tests, medications and treatments.

• Write this information on the concept map.

Vital signs 96.4 R, 68/48, P- 170, R-

80

32 week premie,

Mother SROM, meconium stained,

Beta strep positive – no treatment

• Lonely?

• Bedridden?

• Malnourished?

• Sick?

• Pain?

• Infection?

• Dehydration?

• Social isolation

• Altered nutritional

status

• Ineffective tissue

perfusion

• Altered fluid and

electrolytes

• Impaired tissue

integrity

• At risk for infection

• It is impossible to develop an individualized plan of care unless you have identified and prioritized the patient’s problems.

• The medical diagnosis focuses on the signs and symptoms of the pathological process.

• Nursing diagnoses focus on patient responses to health problems.

• Look for linkages and

associations.

• Define your nursing

diagnoses.

• Prioritize!

• The #1 problem

usually has the most

supporting data.

• Identify therapeutic goals, outcomes and strategies to address each nursing diagnosis.

• Set mutual goals with your patient.

• Interventions help meet these goals.

• Lastly, evaluate your care.

• My patient will:

• Experience bonding and physical touch with parents for 30 minutes today.

• Consume 40% of their meals today.

• Maintain oxygen saturation levels of >95% today.

• My patient’s pain level will be <3 before shift change.

• Assess, observe for

signs and symptoms of

problems.

• Administer medications,

treatments, oxygen,

suctioning.

• Provide comfort

measures, therapeutic

communication.

• Teach patient and family

as needed.

The infant will be assessed hourly

O2 as needed, thermoregulation,

Pacifier provided, feeding via NG tube

Parents encouraged and advised

about therapeutic touch, hand washing

• Lastly, care will be

evaluated.

• Goals were met or not

met.

• What went well and

was successful.

• What was not

accomplished and

may need amending.

• Gather data

• Identify problems on

concept map

• Translate problems

into nursing diagnosis

• Set goals

• Intervene

• Evaluate