Care Mapping
description
Transcript of Care Mapping
![Page 1: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/1.jpg)
Care MappingTechnologies in Nursing
Duquesne University
![Page 2: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/2.jpg)
History of Nursing Diagnosis First introduced in 1950. In 1953 Fry proposed the formulation
of nursing diagnosis. In 1973, the first national conference
was held. In 1982, NANDA was founded.
![Page 3: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/3.jpg)
Critical Thinking and the Nursing Diagnostic Process Diagnostic reasoning
◦ A process of using assessment data to create a nursing diagnosis
Defining characteristics◦ Clinical criteria or assessment findings
Clinical criteria◦ Objective or subjective signs and symptoms
![Page 4: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/4.jpg)
Nursing Diagnosis (Match the term to the definition)
1. Medical diagnosis A. Clinical judgment about the client in response to an actual or potential health problem
2. Nursing diagnosis B. The identification of a disease condition based on specific evaluation of signs and symptoms
3. Collaborative problem C. An actual or potential complication that nurses monitor to detect a change in client status
![Page 5: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/5.jpg)
Formulation of Nursing Diagnosis(Match the term with the definition)
1. Actual Nursing Diagnosis
A. Describe human responses to levels of wellness that have a readiness for enhancement
2. Risk Nursing Diagnosis
B. Describes human responses to health conditions/life processes that may develop
3. Wellness Nursing Diagnosis
C. Describes human responses to health conditions or life processes
![Page 6: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/6.jpg)
Problem Etiology Signs and Symptoms
Components of the nursing diagnosis:
![Page 7: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/7.jpg)
Nursing Diagnosis: Application to Care Planning By learning to make accurate nursing
diagnoses, your care plan will help communicate the client’s health care problems to other professionals.
A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.
![Page 8: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/8.jpg)
Problem—the name or diagnostic label identified from the NANDA list. This may be an actual problem, a risk (potential) problem, or a wellness diagnosis.
Problem
![Page 9: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/9.jpg)
The suspected cause or reason for the response that has been identified from the assessment
Etiology
![Page 10: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/10.jpg)
They are stated “as evidenced by (A.E.B.)” or “as manifested by”, followed by a list of subjective and objective data.
“Risk” problems have no evidence statement.
Signs and Symptoms
![Page 11: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/11.jpg)
Ineffective Airway Clearance, related to increased pulmonary secretions and bronchospasm, evidenced by wheezing, tachypnea, and ineffective cough.
Acute pain related to tissue distention and edema as evidenced by reports of severe colicky pain in right flank, elevated pulse and respirations, and restlessness.
Correctly-Worded Nursing Diagnoses
![Page 12: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/12.jpg)
Hyperthermia related to increased metabolic rate and dehydration as evidenced by elevated temperature, flushed skin, tachycardia, and tachypnea.
Risk for infection, related to broken skin, traumatized tissues, decreased hemoglobin, invasive procedures, increased environmental exposure.
Correctly-Worded Nursing Diagnoses
![Page 13: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/13.jpg)
Risk for skin breakdown related to immobility as evidenced by stage III sacral wound (7 X3 cm)
Right or Wrong?
![Page 14: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/14.jpg)
Pain related to myocardial infarction as evidenced by patient’s report of pain at 9 on the 1-10 pain scale
Right or Wrong?
![Page 15: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/15.jpg)
Ineffective airway clearance related to pneumonia as evidenced by adventitious breath sounds, sputum production, and abnormal chest x-ray.
Right or Wrong?
![Page 16: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/16.jpg)
Fluid volume deficit related to blood loss through wound as evidenced by hemoglobin of 8 and hematocrit of 26%
Right or Wrong?
![Page 17: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/17.jpg)
Fluid volume deficit related to NPO status as evidenced by weight loss
Right or Wrong?
![Page 18: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/18.jpg)
Diarrhea related to C. Diff as evidenced by 10 stool in one day
Right or Wrong?
![Page 19: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/19.jpg)
Risk for infection related to invasive procedure (surgery)
Right or Wrong?
![Page 20: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/20.jpg)
Readiness for enhanced knowledge of disease process.
Right or Wrong?
![Page 21: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/21.jpg)
Based on a medical diagnosis Examples:
◦Risk for pneumonia related to immobility◦Risk for DVT related to immobility◦Risk for myocardial infarction related to
inadequate tissue perfusion
Potential Complications
![Page 22: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/22.jpg)
Written in general termsNot behavioral in naturePatient centeredExample: To enhance airway clearance and improve oxygenation
Primary Goal or Objective
![Page 23: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/23.jpg)
Actions that the nurse carries out for the client or encourages the client to do for themselves.
Include interdisciplinary actions, but identify them as such.
Includes assessment Includes teaching the client Include the rationale for the intervention.
Nursing Interventions
![Page 24: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/24.jpg)
SpecificMeasurableAttainableRealisticTime oriented
Desired behavioral outcomes/goals should be SMART
![Page 25: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/25.jpg)
◦ The patient will identify four adaptive/protective measures for individual situation by discharge.
◦ The patient will maintain a patent airway, ongoing. (This outcome is stated as “ongoing” and does not include a specific timeframe other than discharge from care. In this example, this is appropriate because the situation may not resolve until the patient’s condition or status changes or discharge has occurred.)
Examples of SMART Goals
![Page 26: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/26.jpg)
◦ The patient will be free of skin breakdown. (This is another example of an ongoing outcome).
◦ The patient will demonstrate correct insulin administration techniques within 48 hours.
The patient will attain pain relief identified as a “3” on the 0-10 pain scale 30 minutes after being medicated with pain medication.
The patient will maintain an oxygen saturation of 92 or higher.
The patient will not incur a fall.
Examples of SMART Goals
![Page 27: Care Mapping](https://reader035.fdocuments.in/reader035/viewer/2022070500/56816866550346895ddec916/html5/thumbnails/27.jpg)
Should refer directly to the nursing diagnosis and to the goal.
Evaluation or Outcome