Concept map format for CLA
1. NANDA 3 Part 2. 2nd NANDA
Statement Priority 3 part
Statement
Background: Chief
Complaint
Active Medical
Diagnosis
Summary of AbN
PE Findings
including labs
3. NANDA 3rd
priority (Risk) NDX
1. NANDA 3 Part 2. 2nd NANDA Priority 3
Statement part Statement
Do a 3 part Do a 3 part statement
statement following NANDA rules
following NANDA Includes Assessment
rules interventions,
Includes Assessment nonpharmacological,
interventions, pharmacological
nonpharmacologi Background Intervention
cal, Chief Complaint
pharmacological Active Medical Diagnosis
Intervention Abnormal PE findings
3. NANDA 3rd priority
(Risk) NDX
BASIC Do a 3 part statement
FORMAT following NANDA rules
FOR Includes Assessment
CONCEPT interventions,
MAP nonpharmacological,
pharmacological
Intervention
1. NANDA 3 Part Statement 2. 2 NANDA Priority 3 part Statement
nd
Impaired gas and oxygen
Decreased cardiac output related t
exchange r/2 increase in HR as manifested by HR of
bronchospasm as 101bpm and BP of 160/90
manifested by wheezing 1.Monitor BP, HR. HL, LDL and ECG
and SaO2 of 87% 2. Decrease stressors.
- Assess HR, RR, lung 3. Recommend DASH diet for the
sounds, and SaO2. Patient Background patient.
- Raise the HOB 42 y/o Hispanic female with cc of SOB 4. Administer Metrolol and
- Increase CHON and kcal Medical Dx of Spironolactone as ordered.
in diet Acute asthma exacerbation,
- Increase activity as Hyperlidemia and HTN
tolerated allowing for rest PE FINDINGS
periods VS: HR 101 bpm RR: 23 b/min, BP:
- Reduce oxygen demands 160/90 mmhg saO2: 87 % Pain 310
- Administer montelukas, LOC: AOX 4
singulair, Advair and RESP: (+) posterior wheezes,
ipratropium bromide as Cardio: Sinus Tachycardia
ordered ordered,
3. NANDA 3rd priority (Risk) NDX
Risk for injury related to falls
1.Raise 2 side rails of the bed.
2.WOF for orthostatic hypotension
3.Lower the bed to the lowest possible
level.
4.Put most-used items on the bedside
table and place the bedside table near the
patient
SAMPLE 5.Place call bell within reach.
6.Monitor every 2 hours.
CONCEPT 7.Move the patient’s room closer to the
MAP FOR nurses station.
8.Apply non-skid sign and place a fall risk
CARE PLAN sign in front of the patient’s room
Concept Map for Pathophysiology
CLINICAL DECISION MAKING &
THE NURSING PROCESS
NRS 110
Critical Thinking Revisited
• Knowledge
• Experience
• Reflection
• Intuition
Components of Critical Thinking in
Nursing
• Specific Knowledge Base
• Experience
• Critical Thinking Competencies
• Diagnostic Reasoning
• Clinical Decision Making
• Nursing Process
• Critical Thinking Attitudes
• Critical Thinking Standards
• Intellectual Standards
• Professional Standards
Clinical Decision Making
• Critical thinking process for choosing
the best actions to meet a desired goal
• To act or not to act, that is the question!
• Criteria used to make decisions
• Collaboration
• Problem Identification
• Who is responsible for making the
decision?
Level of Critical Thinking
• Basic
• Complex
• Commitment
NURSING PROCESS
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
The nursing process in action
Step One: Assessment
• Collect data (Types of data, Sources of
data, Methods of data collection)
• Organize data
• Validate the data
• Record & report
Step 2: Diagnosis
• Analysis of
assessment data
leads to problem
identification
• NANDA list
• Types of nursing dx.
Anatomy of a Nursing Diagnosis
• Problem (Diagnostic label)
• Etiology (Related factors and Risk
factors)
• Defining Characteristics
• Differentiating Nursing Diagnoses from
Medical Diagnoses
• Differentiating Nursing Diagnoses from
Collaborative Problems
The Diagnostic Process
• Analyzing data: Compare data against
standards, cluster data, identify gaps
and inconsistencies in data
• Identify health problems, determine
problems and risks, determine
strengths
Formulating Diagnostic Statements
Step 3: Planning
• Set priorities
• Apply standards
• Identify goals &
outcomes
• Select interventions
• Record the plan
(nursing care plan)
What are the priorities?
Maslow’s Hierarchy of Basic
Human Needs
Guidelines for Writing Goal
Statements
• Write goals in terms of client responses
• Be sure the desired outcomes are
realistic and compatible with ordered
therapies
• Make sure that each goal is derived from
only one nursing diagnosis
• Use observable, measurable terms for
outcomes
• Involve the client in the process
CONCEPT MAP Ineffective
Airway Clearance (Gas Exchange)
Step 4: Implementation
• Put your plan into
action
• Perform the
interventions
• Note patient
response to
interventions
• Record & report
Types of Interventions
• Independent (nurse initiated)
• Dependent (physician initiated)
• Collaborative
Step 5: Evaluation
• Did the plan work?
• Was goal achieved?
• What was the
outcome of the care
provided.
• Stated in
measurable terms.
• It’s all about
outcomes!
Case Scenario
• A.A. is an 28 y.o. female who was admitted
with pneumonia. She presents with complaint
of cold x 2 weeks, dyspnea on exertion, ,
orthopnea, decreased oral intake. Assessment
of patient reveals:
• T 103F, P 92, R 22 shallow, BP 122/80
• Dry mucous membranes, hot pale skin
• Decreased breath sounds, inspiratory crackles
• Ineffective cough-coughing up thick pink
sputum
• Lethargic, c/o being weak
Now lets write the plan down!
Concept Map Steps
• Place your main issue/problem in the middle
• Determine key problems/concepts that have a
direct relationship to the main problem
• Add clinical data to appropriate problem boxes
• Draw lines between related problems. Label
with a nursing diagnosis
• Identify goals/outcomes
• Add interventions
• Evaluate patient response to interventions
CONCEPT MAP Ineffective
Airway Clearance (Gas Exchange)
