Care map case study

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NSG110IndividualCaremapInstructionsT520207.doc

School of Nursing

Care Mapping Instructions AND the instructions for the Analysis (Explanation) paper

The care map is a diagramed version of the nursing process and it is “used to organize patient data, analyze relationships in the data, establish priorities, build on previous knowledge, identify what you do not understand, and enable you to take a holistic view of the patient’s situation (Schuster, 2002).”

Mapping out thought process helps the instructor understand how the student is thinking about nursing process and planning care. Care maps can stand on their own. Nursing students must be able to discuss what they have done. Therefore, each part of the Individual Care Map assignment requires an analysis paper and a care map. The best part about this is that both build upon the previous part.

This is what you do:

Individual Care Map Part 1:

Read the case study.

Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box. Slide #2

Organize the data from the case study by completing the table on the care map (second slide):

Body Systems

Subjective Data

Objective Data

Neurologic

HEENT (Head, Eyes, Ears, Nose, Throat)

Integument

Musculoskeletal

Cardiovascular

Respiratory

GI

GU

Emotional/Social/Spiritual

Reproductive

Step 2: Group the subjective and objective data that belong together in the same data cluster. Identify the correct Gordon’s Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed. Slide #3

Explanation:

Which of the data cues are related to each other? Cluster those data cues together (data clusters) and on the care map by placing the data clusters in text boxes around the patient image. Connect the data to the patient.

Data Cluster #1 (example):

i.e. the patient states pain level “8/10”, “I can’t move right now.”, grimacing, pointing to RLQ, incision in RLQ of abdomen, HR 98, Bp 138/90, guarding abdomen (these data cues are clustered together because they demonstrate that the patient is in pain)

1. pain level 8/10

2. grimacing, pointing to RLQ of abdomen

3. incision in RLQ of abdomen

4. guarding abdomen

5. HR 98, Bp 138/90

6. States, “I can’t move right now”

add more as needed

Data Cluster #2 (and so forth until all the data cues are clustered and identified

in at least one of the Gordon’s Patterns.)

Review the worksheet of Gordon’s Patterns. Which of Gordon’s Patterns are represented by the data clusters? How do you know this? READ THE DEFINITIONS and Label the connecting lines of data clusters from the patient with the Gordon’s patterns:

What is the purpose of labeling these connecting lines? It helps a nurse to determine if more assessment data is needed to make a decision and it helps us to use Gordon’s patterns to select associated nursing diagnoses to label the response of the patient to the situation.

Step 3: Getting to the problems (slide #4):

1. Type in the Data Clusters.

2. Identify the Gordon’s Pattern and functionality;

3. Analyze the data cluster to determine the problem.

4. Identify the appropriate Nursing Diagnostic Label (nursing problem).

5. Complete the remaining sections.

6. Include arrows showing how each data cluster/problem

influences others on the care map.

7. Add, Expand, or Rearrange the boxes as needed.

Now, Which of the Gordon’s Patterns are dysfunctional?

Label those. That means it’s a problem!

Process for writing a Nursing Diagnosis:

Now the fun part! Determining relevant associated Nursing Diagnoses (also called the diagnostic label, problem, or diagnosis). Go to Appendix H of the Donges book. We talked about this in class. There are so many nursing diagnoses that it may seem overwhelming. For each data cluster, try to determine by looking at the defining characteristics of the data clusters (defining characteristics = data cues) which Nursing diagnosis is associated. For example:

States pain level “8/10”, “I can’t move right now.”, grimacing, pointing to RLQ, incision in RLQ of abdomen, HR 98, Bp 138/90, guarding abdomen

· I read that the client is in pain, so I’m going to the “p’s” to see if pain is there, and it is! I have to decide now, is it chronic or acute pain. READ THE DEFINITION. By the definition, the client is in acute pain.

· Next, do the defining characteristics match up? They do. So, this looks like a good choice for this data cluster.

· Finally, what is the cause of the problem? This is also called the etiology, related to, or risk factors. And, Donges has a list of related to factors waiting for you to consider. The most important part of this consideration of the cause of the problem is that you do not select a medical diagnosis ; because the nurse cannot “cure” the patient of the medical diagnosis (that’s the physician’s job). We relieve the response to the situation and promote health.

Once the diagnostic labeling is complete (the nursing diagnosis) and the cause of the problem is determined (related to) and the evidence is included, put it together into a two-part or three-part diagnostic statement:

Repeat the process for each data cluster and create a list of nursing diagnoses that are associated with the Gordon’s patterns selected based upon the data clusters.

Step 4: Prioritize the Nursing Diagnoses:

We did this in class. There are several methods and some may be more applicable to your client’s situation. Start by setting up a table to help you organize the nursing diagnostic labels:

 

Problem-oriented

Risk/ potential

Health Promotion

Physiological

 

 

 

Psychosocial

 

 

 

Educational

 

 

 

(hint: ABC’, the table above, Maslow’s, etc)

In the appropriate space on the care map do the following:

Write in your own words: What is the more important (priority) problem for this client? (what worries you the most?)

Then:

1. List all of the nursing diagnostic statements in priority order on the care map.

2. Type in the PRIORITY nursing diagnostic statement into the correct space on the care map.

3. Write one Goal statement indicating resolution or reduction of the patient problem.

4. Write 2-3 SMART outcome statements indicating goal achievement.

Clustered Data (all relevant)

1. pain level 8/10

2. grimacing, pointing to RLQ of abdomen

3. incision in RLQ of abdomen

4. guarding abdomen

5. HR 98, Bp 138/90

6. States, “I can’t move right now”

Relevant Gordon Pattern: Cognitive/perception

Definition: the client’s mental status including sensory: sight, auditory, touch, taste, smell, and pain (citation)

Clustered Data (all relevant)

1. pain level 8/10

2. grimacing, pointing to RLQ of abdomen

3. incision in RLQ of abdomen

4. guarding abdomen

5. HR 98, Bp 138/90

6. States, “I can’t move right now”

Relevant Gordon Pattern: Cognitive/perception -dysfunctional

Associated Nursing diagnostic label: Acute pain