Concept Mapping

...for the slightly confused

Diana Benton RN - 2010

Whats a concept map anyway?

...an innovative approach to planning and organizing nursing care ...focused on a holistic nursing view of the patient, rather than a disease model

For the student

...helps with organizing the problems and care of patients in a logical fashion ...guides the students focus so he or she can learn to analyze relationships in
clinical data and to prioritize the needs of a specific client

For the instructor

... a visual representation of the

critical thinking ability of inexperienced nurses

A description well expand upon is...

A concept map is a diagram of the sequential steps of the nursing process.

1. 2. 3. 4. 5. assessment nursing diagnosis goal intervention evaluation

Lets get started...

This is D.J. - he fractured his right femur when he jumped off the roof. Youd think a 42 year old guy woulda known better!

Although there are many different ways to make a concept map

lets do it my way and... D.J. 42 year old male Admitting dx: Fx Right Femur

...start with a circle in the center of the paper identifying the patient.

Then, to plan the patients care, youll utilize...

the nursing process

To begin....

ssess the patient

and gather subjective and objective data

MY LEG HURTS !

Subjective Assessment Data

(information that only the client feels and can describe)

Concurrent Health Problems

Objective Assessment Data

(observable or measurable facts)

Pertinent Labs and Diagnostic Tests

Make 2 more circles. It will help you remember to check D.J.s chart for additional objective data and besides, you could use the extra space!

Lets see how this assessment data looks when added to your concept map

Subjective Assessment Data

Needs Further Assessment

If you realize you need to get more information .. make a note here to remind yourself

c/o Pain (R) leg c/o nausea depressed dizzy

D.J. 42 year old male Admitting dx: Fx Right Femur

Concurrent Health Problems
None

Objective Assessment Data

BP = 150/68 Pulse = 98

Pertinent Labs and Diagnostic Tests

Pallor
Bucks traction (R) leg Moaning

Xray: (R) femoral neck fracture

Now to come up with a...

ursing
iagnosis

Look at the assessment data. Identify patterns of related responses to an actual or potential health problem.
Xray: (R) femoral neck fracture

ACUTE PAIN
Based on the problem identified, chose an appropriate nursing diagnosis from the NANDA list.

Add this nursing diagnosis to your concept map.

Nursing Diagnosis:

ACUTE PAIN

Subjective Assessment Data c/o Pain (R) leg c/o nausea depressed dizzy

Needs Further Assessment

D.J. 42 year old male Admitting dx: Fx Right Femur

Concurrent Health Problems

You must be able to show the relationship between each nursing diagnosis you chose and the assessment data upon which it was based.

Objective Assessment Data BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

None

Pertinent Labs and Diagnostic Tests Xray: (R) femoral neck fracture

As you add more diagnoses...

Another Diagnosis ACUTE PAIN

Another Diagnosis
... your map can begin to look like a confusing mess.

Skip the lines.

Instead... use a 3 part nursing diagnosis that includes:

Diagnosis

Nursing Diagnosis:

ACUTE PAIN

Cause related to

R/T (R) femoral neck fracture

Indicators as evidenced by

AEB c/o Pain (R) leg / moaning / BP = 150/68 / pulse 98

When added to your concept map it should look like this:

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture

ACUTE PAIN

Subjective Assessment Data c/o Pain (R) leg c/o nausea depressed dizzy

Needs Further Assessment

c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

D.J. 42 year old male Admitting dx: Fx Right Femur

Concurrent Health Problems

Objective Assessment Data BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

None

Pertinent Labs and Diagnostic Tests Xray: (R) femoral neck fracture

After you have decided on a nursing diagnosis, set a patient-focused...

oal
specific measurable attainable realistic timely

so you will be able to determine if desired outcomes of care are achieved

ACUTE PAIN

So whats gonna be your patient-focused goal

The

will...

...have no pain

he just broke his leg...its gonna hurt!

...report pain controlled at a tolerable level

this is more realistic but...

How are you gonna determine if the pain is tolerable

specific

reports pain levels of < 5 on a scale of 0 to 10 within the next 24 hours

attainable realistic timely

measurable

Now thats a

smart

goal

Put this goal on your concept map.

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

ACUTE PAIN

Subjective Assessment Data c/o Pain (R) leg c/o nausea depressed dizzy

Needs Further Assessment

Goal:

The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours

D.J. 42 year old male Admitting dx: Fx Right Femur

Concurrent Health Problems

Objective Assessment Data BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

None

Pertinent Labs and Diagnostic Tests Xray: (R) femoral neck fracture

Now you need to decide on nursing... nterventions

that, when implemented, will enable the patient to achieve the stated goal

Explain 0 to 10 pain scale / need not wait until pain is severe

Administer ordered pain meds prn / assess pain relief 30 min. after medicating Maintain Bucks traction to muscle spasms Refresh ice to right femur prn Provide periods of uninterrupted rest

Add your interventions.

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

ACUTE PAIN

Goal:

Subjective Assessment Data c/o Pain (R) leg c/o nausea depressed dizzy

The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours

Needs Further Assessment

Interventions: Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Bucks traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

D.J. 42 year old male Admitting dx: Fx Right Femur

Concurrent Health Problems None

Objective Assessment Data BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

Pertinent Labs and Diagnostic Tests Xray: (R) femoral neck fracture

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

ACUTE PAIN

Goal:

The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Interventions:
Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Bucks traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Subjective Assessment Data

c/o Pain (R) leg c/o nausea depressed dizzy

Following the same sequence of steps, you can develop additional nursing diagnoses along with goals and interventions.
Needs Further Assessment

D.J. 42 year old male Admitting dx: Fx Right Femur

Nursing Diagnosis: Goal:

Concurrent Health Problems
None

Nursing Diagnosis: Goal:

Objective Assessment Data

BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

Interventions:

Pertinent Labs and Diagnostic Tests

Xray: (R) femoral neck fracture

Interventions:

At this point...
prioritize the needs of your patient based on Maslows Hierarchy of Needs.

Selfactualization

Esteem
feeling of accomplishment

Love and belonging

intimate relationships and acceptance

Safety
feel safe and avoid danger

Physiological needs basic to human survival

oxygen, water, food, shelter, and sleep

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

ACUTE PAIN

Goal:

The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Number each nursing diagnosis on your concept map in order of priority.

ACUTE PAIN Subjective Assessment Data
c/o Pain (R) leg c/o nausea depressed dizzy

Nursing Diagnosis:

Interventions:
Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Bucks traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest.

Needs Further Assessment

D.J. 42 year old male Admitting dx: Fx Right Femur

Nursing Diagnosis: Goal:

Concurrent Health Problems
None

Nursing Diagnosis: Goal: Interventions:

Objective Assessment Data

BP = 150/68 Pulse = 98 Pallor Bucks traction (R) leg Moaning

Interventions:

Pertinent Labs and Diagnostic Tests

Xray: (R) femoral neck fracture

Lastly, do an...
valuation
of the effectiveness of the interventions in relation to goal set
if goal is not being met, what changes do you need to make?

Nursing Diagnosis:
R/T AEB (R) femoral neck fracture c/o Pain (R) leg / moaning / BP 150/68 / pulse 98

ACUTE PAIN

Subjective Assessment Data c/o Pain (R) leg c/o nausea depressed dizzy D.J. 42 year old male Admitting dx: Fx Right Femur Objective Assessment Data BP = 150/68 Pulse = 98 Pertinent Labs and Diagnostic Tests Xray: (R) femoral neck fracture Concurrent Health Problems None Needs Further Assessment

Goal:

The patient will report pain controlled at levels of < 5 on a scale of 0 to 10 within the next 24 hours.

Interventions: Explain 0 to 10 pain scale / need not wait until pain is severe. Administer ordered pain meds prn / assess pain relief 30 min. after medicating. Maintain Bucks traction to muscle spasms. Refresh ice to right femur prn. Provide periods of uninterrupted rest. Evaluation: Goal met patient reports pain controlled between levels 1 - 4 during past 24 hours

Pallor
Bucks traction (R) leg Moaning

Yea, you just made a...

... concept map!

Wasnt that easy?