Transcript Looking Up Information

Chapter 3
Concept Mapping:
Grouping Clinical Data in a
Meaningful Manner
劉芹芳
楊玉娥
周汎澔
林麗娟
Objectives
1.
2.
3.
4.
5.
6.
7.
Identify the ANA nursing standard of care related to
organizing patient data.
Identify primary medical diagnoses.
Review patient profile data to determine general health
problems.
Categorize patient profile data under health problems
resulting from the patient’s response to the health
problem.
List primary assessments associated with the medical
diagnosis.
Label nursing diagnoses.
Specify relationship between nursing diagnoses.
Concept Map
Assessment data
(use critical-thinking
skills to organize data)
Nursing diagnoses
3 Steps to Develop a Concept Map
1.
2.
3.
Develop a basic skeleton diagram (to
formulate initial impressions of the clinical
patient profile data)
Analyze and categorize data (to arrange
data in hierarchical order)
Label diagnoses—Analyze relationships
between problems (to make meaningful
associations between segments of the
map)
Scenario
 Age：80
y/o
 Sex：M
 Admission
date：3/21
 住院原因：Diabetes
 醫學診斷：New onset diabetes（defined
above）
History of hypertention
Scenario—續
 Laboratory
data：
blood glucose：450
glycohemoglobin：12％
cholesterol：240
urine analysis：3+ sugar,
no ketones,
no protein,
no WBCs,
clear yellow
Scenario—續
 Medications
Humulin N 35U q.A.M., 7：30 A.M.
Valsartan 80mg q.A.M., 9 A.M.
Acetaminophen 650mg, q4h, p.r.n.
 Treatments
Accu-check q.i.d., ac & hs
Support Service：Dietary
Consultations：Diabetes educator
Scenario—續
 Type
of diet：1800 ADA
 Intake：2200
Problems：swallowing, chewing, dentures
（nurse’s notes）
Needs assistance with feeding（nurse’s notes）
Nausea or vomiting（nurse’s notes）
Overhydrated or dehydrated（evaluate total I/O）
Belching
Other：history of polyphagia

Urine Output：1800
Scenario—續
 Activity：Weakness
 Physical
assessment
BP：138/92
TPR：98.4 – 77 – 19
Height：175㎝
Weight：79㎏
Scenario—續
 Neurological/Mental
Status
alert and oriented to person, place, time
 Religious
preference：Catholic
 Marital Status：Widower
 Occupation：Retired
 Emotional state：
Anxious about giving insulin and following diet
Step 1-1
Develop a Basic Skeleton Diagram
Database for Patient with Diabetes
Step 1-1: Develop a basic skeleton diagram
Map the framework of propositions
a. find patient’s key problems
concepts
b. start by centering the medical diagnosis
Nutrition
Elimination
Learning
Newly Diagnosed
Diabetes
Anxiety
BP problems
Step 1-2
Looking Up Information
 Drugs
 Laboratory
and Diagnostic Tests
 Diet
 Medical
Diagnoses
Step 1-3
Preventing Falls and Skin
Breakdown
Assessment Directions
Place an “x” in front of elements that apply
to your patient. Based on the assessment,
check whatever applies to the patient. A
patient for whom you place four or more “x”
marks is at risk for falling
General Data
X Age over 60
__History of falls before admission
__Postoperative/ admitted for operation
__Smoker
Physical Condition
__Dizziness/ imbalance
__Unsteady gait
__Diseases/ other problems effecting
weight-bearing joints
X Weakness
__Paresis
__Seizure disorder
__Impairment of vision
__Impairment of hearing
__Diarrhea
X Urinary frequency
Medications
__Diuretics or diuretic effects
X Hypertensive or CNS suppressants drugs
__Postoperative/ admitted for operation (e.g.,
narcotic, sedative, psychotropic, hypnotic,
tranquilizer, antihypertensive,
antidepressant)
__Medication that increase GI motility
Ambulatory Devices Used
__Cane
__Crutches
__Walker
__wheelchair
__Geriatric (geri) chair
__Braces
Mental Status
__Confusion/ disorientation
__Impaired memory r judgment
__Inability to understand or follow directions
Step 2: Analyze and Categorize
Data
圖3-1
Elimination
I =2200
O =1800
Polyuria
Nutrition
Polydipsia
I =2200
O =1800
Weakness
79㎏
Learning
Newly Diagnosed Diabetes
BP Problems
138/92
Anxiety
Not Sure：
Skin breakdown？
Figure 3-1
Step
3：Label Diagnoses—Analyze
Relationships between Problems
Many students have a tendency to select nursing
diagnoses too quickly, without first looking at and
organizing all data.
1.NANDA system
2.Gordon’s Functional Health Patterns
3.NANDA’s Human Response Patterns
 Figure
3-4-1
 Figure
3-4-2
Summary
 Psychosocial-cultural
assessment
-- 請看Chapter 6
 The
purpose of this chapter was to take you
slowly through the first three step of the
concept map care planning process.
 自行練習：請參考附件