Concept Mapping for Practical Nursing Concept Mapping Goals Apply care planning with a holistic view of individual clients Critically think about interconnections between data associated with client problems Encourage “whole-brain” thinking What is Concept Mapping? Visual representation of your thinking processes as you plan and implement nursing care Use all elements of nursing process Help you to see “big picture” What is Concept Mapping? Interconnect data from various sources Signs and symptoms/Assessment data Past medical history Laboratory and diagnostic data Medications and medical interventions Family/Psychosocial data Getting Started Use a large piece of scratch paper then transfer data to your worksheet(s) Use pencil on scratch paper Can be messy at first Be prepared to do a lot of erasing Use ink for final copy on worksheet(s) Construction of a Concept Map Start with client Client is center of map Map #1: Client Information Placed in center of page Patient initials Age Sex Medical diagnosis Admitted from MJ 74, male CHF Admitted - Home Map #1: Assessment/Data Creating Clusters Assess your client (Be specific) Document ALL assessment data on front of your Nursing Worksheet Review data and underline or highlight all abnormal data Group data into data clusters based on interrelationships of data Map #1: Assessment/Data Clusters Review S&S on your diagnosis cards See how data interrelates Put similar data into groups Give each group a simple name DO NOT use systems “How do all of these things affect my client?” Data can be in more than one cluster Data Clusters Breathing Problems Self-Concept Elimination Skin Safety Activity Communication Self Care Nutrition/Fluid Cognitive/Perceptual Map #1: Assessment/Data Clusters Use as many data clusters as you need Look at data clusters, does all of this data relate? Does label fit all data? Prioritize ALL data clusters. Base this on theory. Remember Maslow or Peplau. Pick your top 2 priority data clusters and place them on concept map Remember to number them on concept map Map #1: Assessment/Data Clusters You will only list ACTUAL PROBLEMS Risk problems have a separate area Number actual problems by priority Then number risk problems Data Clusters Breathing Problems 1 or 2 Fluid 1 or 2 Skin 5 Falls 9 Mobility 6 Nutrition 4 Elimination 7 Communication 10 Self Care 8 Mental status 3 Map #1: Place top 2 priority data clusters around client 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases 2 MJ 74, male CHF Home 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Map #1: Past Health History Client may have past health history or other health problems Make an additional box for this information and place on concept map Map #1: Past Medical History 2 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases MJ 74, male CHF Admitted - Home Type 2 DM Hypothyroidism HTN PVD BPH 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Map #2: Risk Problems Important issues are on your problem list that affect care, but are not existing problems at this time are risk problems List these, in proper diagnosis format, in an additional “box” on concept map Clients will have more than one risk problem Map #2: Risk Problems 1 2 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Type 2 DM Hypothyroidism HTN PVD BPH MJ 74, male CHF Admitted - Home Risk for falls R/T weakness and fatigue Map #2: Nursing Diagnosis Look at each cluster of assessment data Pick Nursing Diagnosis that fits data cluster Make a new “box” and place it above data cluster Place Nursing Diagnosis in box Nursing Diagnosis ONLY from NANDA list Add your related to factors (R/T) Activity intolerance R/T imbalance B/W O2 supply and demand AEB 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases Excess Fluid volume R/T water retention AEB MJ 74, male CHF Admitted - Home Type 2 DM Hypothyroidism HTN PVD, BPH Risk for falls R/T weakness and fatigue 2 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Map #3: Goal/Plan Add client goals Measurable and realistic What you want to accomplish with your nursing care/interventions? It should be the client’ goals, not your goals ONE goal for each problem Activity intolerance R/T imbalance B/W O2 supply and demand AEB Excess Fluid volume R/T water retention AEB 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases MJ 74, male CHF Admitted - Home Pt will be able to ambulate 12 feet W/O resting by ____ 2 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Pt’s lungs will be clear to auscultation by ________ Type 2 DM Hypothyroidism HTN, PVD, BPH Risk for falls R/T weakness and fatigue Map #4: Interventions Add nursing interventions for each nursing diagnosis Need AT LEAST 3 nursing interventions Write as many as you feel are necessary Make sure at least 1 or 2 are actions Remember to add anything you are currently doing Activity intolerance R/T imbalance B/W O2 supply and demand AEB Excess Fluid volume R/T water retention AEB 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases 2 MJ 74, male CHF Admitted - Home Pt will be able to ambulate 12 feet W/O resting by ____ 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Pt’s lungs will be clear to auscultation by ________ Monitor O2 saturation QS Assist OOB to chair TID Provide periods of rest Type 2 DM Hypothyroidism HTN, PVD, BPH Risk for falls R/T weakness and fatigue Monitor I & O QS Monitor daily weight Monitor lung sounds Q4 hr Encourage C&DB Map #5: Medications and Labs Add medications/treatments Add your laboratory/diagnostic data Place under nursing diagnosis which they relate to Activity intolerance R/T imbalance B/W O2 supply and demand AEB Excess Fluid volume R/T water retention AEB 1 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases 2 MJ 74, male CHF Admitted - Home Pt’s lungs will be clear to auscultation by ________ Pt will be able to ambulate 12 feet W/O resting by ____ Monitor O2 saturation QS Assist OOB to chair TID Provide periods of rest Lasix O2 2l NC Titrate to Sat>93% PaCo2 – 50 pH – 7.30 HCO3 – 28 CXR = Effusion 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Type 2 DM Hypothyroidism HTN , PVD, BPH Risk for falls R/T weakness and fatigue Monitor I & O QS Monitor daily weight Monitor lung sounds Q4 hr Encourage C&DB Lasix potassium BUN – 36mg/dL Na – 130mEq/L K – 3.0mmol/L Map #5: Interconnections Interconnections are linkages between problems These exist in a cause or effect relationship Begin to look for interconnections Client is connected to each and every problem in some way Help you to see actual connections in a very concrete manner Map #5: Interconnections one problem directly causes another problem, use a solid arrow from cause to effect If one problem indirectly causes another problem, use a dotted arrow from cause to effect Start at client How does past medical history interconnect? If Activity intolerance R/T imbalance B/W O2 supply and demand Excess Fluid volume R/T water retention 1 2 SOA with exertion Unable to walk 12 ft without resting O2 sat from 94to 88% RR from 18 to 24 with activity O2 at 2L NC Crackles in bases MJ 74, male CHF Admitted - Home Pt will be able to ambulate 12 feet W/O Resting by ____ Pt will maintain a Sat >93% by ___ Monitor O2 saturation QS Assist OOB to chair TID Provide periods of rest Lasix O2 2l NC Titrate to Sat>93% PaCo2 – 50 pH – 7.30 HCO3 – 28 CXR = Effusion 500cc intake, 250cc output Crackles in bases Pitting edema in BLE HR 100 SOA with exertion Pt output will equal intake by___ Pt’s lungs will be clear to auscultation By ________ Type 2 DM Hypothyroidism HTN, PVD, BPH Risk for Falls R/T weakness & fatigue Monitor I & O QS Monitor daily weight Monitor lung sounds Q4 hr Lasix potassium BUN – 36mg/dL Na – 130mEq/L K – 3.0mmol/L Evaluation If you have opportunity to care for client a second day, you may evaluate if plan of care has worked for any short term goal It is good to practice evaluation, discuss in post-conference Please Feel Free To Be Creative You can write them, type them, use colors, or highlighter Use different shaped boxes You must keep basic components Presentation is up to you Past Health History High Risk Problems 1 2 ND RT ND RT AEB Goals AEB Meds Treatments Goals Meds Treatments PMH ND 1 RT AEB Meds 2 ND RT AEB Risk Problems Meds Nursing Diagnosis Meds AEB Goals Treatments Concept Mapping in Long Term Care Your concept map in long term care will look very different from your concept map in acute care In acute care, we focus on actual problems that require immediate intervention to correct client’s problems In long term care, we focus on actual problems that require maintenance in order to prevent further decline in condition Impaired mobility R/T neurological impairment 2 ROM (R arm contracture) Strength (able to resist force with L leg only) Sara Lift to transfer Resident will maintain ability to bear wt. on LLeg and transfer with Sara Lift with every transfer, ongoing 1. Perform ROM exercises to each extremity 2. Use Sara Lift to transfer OOB and to reposition q 2hr 3. Assess need for pain medication prior to transfer Risk for Falls R/T decreased ROM and strength Impaired Swallowing R/T Neurological Impairment MJ 74, male CVA Admitted - Home 1 Coughing and choking when eating History of aspiration pneumonia Pocketing food Thickened liquids Resident will swallow without coughing or choking with all intake, ongoing. Pt will maintain clear lungs to auscultation, ongoing Type 2 DM Hyperlipidemia HTN , CAD, Pneumonia 1. Position resident upright at 90 degree angle/head flexed 45 degrees for all feedings 2. Place food on unaffected side of tongue. 3. Cue resident during feeding WBC 18,000 CXR Infiltrates Augmentin