History and Physical Assessment

History and Physical Assessment

School of Nursing

Care Mapping

(Attachment 7)

Building upon the learning process for planning care through care mapping in NSG 110 and NSG 120, each student will create at least one care map in each clinical.

Select the patient from the clinical rotation and obtain approval from your clinical instructor to assure this patient is appropriate for the care mapping assignment.

Using the Care Map Template create a plan of care map of a select patient. Students’s name must be on the care map and the write up of the questions.

Steps in care mapping (each section shall include the complete and accurate patient information):

1. Identify the patient’s medical diagnosis, problem, or reason for seeking health/medical care. (By week 4)

Medical Diagnosis A description of the problem or reason for seeking care.

This portion should include:

· pathophysiology-include a description of what the disease process is, who does it affect and when, where does it affect them and why it affects them (risk factors)

· signs and symptoms of the disease/disorder

· how the disease/disorder is diagnosed

· and typical treatment (medical and surgical)

2. Nursing Assessment. This is the patient assessment by the student nurse and it comes from a variety of sources:

History and Physical Assessment Findings:

History: Genitourinary:

Neuro/Sensory/Mental Status: Gastrointestinal:

HEENT: Integumentary:

Cardiac: Musculoskeletal:

Respiratory: Reproductive:

Emotional/Social/Spiritual:

***Physical assessment should involve inspection, auscultation, palpation & percussion.

Laboratory and diagnostic tests

Pharmacologic therapies in a table: (Medication name, individualized indications, dose, route, frequency, time, top three side effects pertinent to the medication, contraindications, if any)

3. Assessment Analysis – Analyze the data gathered (learned in NSG 110):

· Cluster the data into patterns and identify the Gordon’s Functional Health Patterns. Indicate whether the pattern is functional or dysfunctional.

· Determine Associate Nursing Diagnoses based upon the Selected Gordon’s Patterns

4. Identify nursing diagnoses (problems that represent the patient’s responses to the medical diagnosis).

· Nursing Diagnosis (NANDA)

· Related to (what factors are causing the problem) _______________________________

· As evidenced by (assessment findings- the evidence that a problem is occurring)

***Reminder to review the parts of a Problem-Oriented diagnosis, a Risk diagnosis, and a Health Promotion diagnosis.

5. Select the Priority Problems in each Category : Physiological, Psychosocial and Educational needs (only NSG 315 and NSG 430)

6. Develop plans of care in the appropriate template to alleviate the problems Each plan must have the following:

a. an appropriate nursing diagnosis,

b. patient-centered goal statement,

c. Patient-centered SMART outcomes,

d. evidence-based interventions,

e. and evaluation criteria.

***Reminder about steps in the nursing process as learned in NSG 110:

· Goals are broad, measurable, patient-centered statement.

· Outcomes are specific, measurable, realistic and concise steps that the patient must accomplish to achieve the general goal. Outcomes should flow from the nursing diagnosis. The student should aim to alleviate the problems identified in the “As Evidenced By” portion of the nursing diagnosis.

· Each Nursing Intervention shall include evidence-based rationale with citation in APA format. Interventions should be individualized to the patient’s needs.

· Patient education and discharge planning should be included in the interventions.

· Evaluation criteria should state whether the outcomes are met. If outcomes have not been met, how are you going to revise the plan of care?

7. Students shall answer the questions at the end of the care map template using appropriate grammar, spelling, syntax. Additional instructions for writing the paper are on the template and below:

Write about what you just did and how you thought about it. Each Gordon’s Functional Pattern set shall be a paragraph. Describe the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume your instructor knows anything about your thought process, because they don’t. Show your instructor how you are thinking! How to begin…………….

On a separate page: Name and date; Include ALL of the questions with the Answers of the questions:

1. In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s Patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped.)

2. Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).

3. List the identified nursing diagnoses in the:

“Problem” Related to “_____ “ Evidenced by “____” format.

4. Which nursing diagnosis is most important to address with this client? Explain how this was determined.

5. Which nursing diagnosis is second most important to address with this client? Explain how this was determined.

6. Which nursing diagnosis is least important to address with this client? Explain how this was determined.

7. Describe the evaluation of the client for each nursing diagnosis?

· Care maps are due in week 6 and student must earn ≥ 80% (within two attempts) to pass the care map and clinical portion of the course.

· Should a revision of the clinical care map be required, the revision is due in week 8.

Be prepared to present your concept map to your fellow students during post conference the last week time permitting.

All material that is not original work shall be referenced in APA format with appropriate in-text citations. Work that is not original and not referenced will not be graded and could result in a grade of zero.

The concept map is supporting documentation for you to use to develop a plan of care specific to your patient and justifies everything you do for your patient.

It should be specific enough that you could hand it to another nurse so the care for your patient could be continued.

The concept map is a written 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).”

The nursing process involves critical thinking and is the foundation of what nurses do. The steps are:

· Assessment- gathering clinical data from a variety of sources to support the decisions you make about the patient.

· Diagnosing- identifying problems that represent the patient’s responses to the medical diagnosis, problem, or reason for seeking care.

· Planning- developing a plan, with goals, to alleviate the problems.

· Implementing- providing the care based on the plan you created.

· Evaluating- reviewing the care you provided and determining whether the care provided has alleviated the patient’s problems and that the goals you set have been reached.

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