Explanation on Concept Map

Overview:

The purpose of this assignment is to identify and prioritize key concepts about your patient in the clinical setting and to synthesize what has been learned in the classroom setting by creating and implementing a plan of care tailored to your patient, setting realistic goals with a timeline, and evaluating your plan of care based on whether the patient has met the goals set forth.

Components:

The components of the nursing concept map should include a brief overview of the patient, 4 nursing diagnoses, supporting subjective and objective data, pt goal, nursing interventions and rationale, and evaluation of goal.

Background information should include your pt’s initials, age, allergies, the reason for hospitalization, past medical history, and assessment priorities based on the reason for hospitalization and current condition. Example: If the patient is admitted with CHF, your assessment priorities would be cardiac and respiratory systems as well as activity level, I&O, etc.

Nursing diagnoses should be approved NANDA nursing diagnoses in the standard form. XXX related to xxx. You can give your evidence in the section with subjective and objective data which should include items such as patient complaints/statements, vital signs, lab values, physical assessment findings, diagnostic imaging results, etc.

The patient’s goal should be your goal for the patient based on the nursing diagnosis that was picked. This goal should be attainable and measurable. A timeline needs to be set for the goal as well. Example: Nursing diagnosis of Pain related to surgical procedure AEB pt reporting 8/10 pain at the surgical site, tachycardia and tachypnea on exam, pt grimacing with movement and deep breathing; Goal: Pt will report pain level reduced to 4/10 within 1 hour, Pt’s blood pressure will be less than 120 systolic within 2 hours, Pt will be able to cough and deep breathe without limitation by pain within 2 hours.

Nursing interventions for the goal should include the intervention and rationale as to why this intervention would be helpful. There should be at least 4-6 nursing interventions for each nursing diagnosis. Some of your interventions need to be actual interventions and not just “monitor this, assess that.” What did you do for your patient while you were there?

Evaluation of the goal should include follow-up subjective and objective findings that support whether your goal was met. It isnot a list of things you would do to evaluate if your goal was met. It is your actual evaluation of the goal that you made for your patient at the beginning of the shift. It is not a requirement that you meet your goal. If your goal is not met, think about if there is something you could have done differently to meet the goal, whether your timeline was realistic, if there were barriers to meeting your goal, or if your goal needed to be adjusted. It should include follow up.

Format:

template attached below

case study Attached