Concept Map Directions
You will submit one data packet that contains two concept maps by the due date on Blackboard. You will have to collect data at clinicals to complete your concept map. There are tons of resources on the internet on concept mapping if you need extra assistance. You will receive a copy of a sample concept map for reference and the format it should be done.
One data packet; 2 nursing diagnosis for the maps (1 per map), information sheet will be all inclusive of medical history, present/current history, treatments. (Make sure to go in-depth for the history – years for surgeries, etc.).
1. Use the diagnosis for admission to the hospital and if there is more than one include all.
2. List ALL medical history (HTN, CAD, DM, CHF, Asthma, Pneumonia, etc) and treatments.
3. Take the top two problems and create the NANDA nursing diagnoses (2). You may use Taber’s or any scholarly source; be thorough. (Do not use Taber’s online)
4. Decide what your overall statement will be for your goals. This will be your NOC statement; needs to simply state your goals in one sentence.
5. Using your NOC, create three (3) goals for each diagnosis; they must be SMART (Specific, Measurable, Attainable, Realistic, Timely). 2 short term and 1 long term goal. Use your nursing diagnosis book.
6. Develop the NIC statement and interventions (3) for each goal ; this is what the nurse will do to assist the client in meeting the goals. Use your nursing diagnosis book.
7. Pathophysiologic rationale for each intervention (3) ; explain why systemically. Rationales should include citations!
8. Evaluate each goal (3) ; 2 short term and 1 long term. Annotate whether goal was met or not, how, and why. Should it be continued or discontinued? What else will you do if the goal is not met?
In summary
You will have one complete data packet. This data packet will begin with a cover page that lists your name, course number, due date, etc.
Everything MUST be in APA 7th edition format, especially reference page – use APA Guide in Blackboard Resources or go to Writing Lab.
· One (main) medical problem, use in both maps
· A nursing diagnosis (per map, so 2 total)
· Nursing goals (should have two short term goals and one long term goal)
· Assessment on nurses note (include vs., pain, head to toe, FHT, blood sugar…) Make a note in map to see nurses note for full assessment, but include key information from assessment in map.
· Interventions (what you will do to help your patient meet the goal – Action)
· Rationale (why is this important; physiologic, etc.) Must be cited.
· Evaluation (This is in short statement; stating whether the client met the goal or need to modify it or discontinue it and why/how it was met or not met)
· Medications – Just list name, dosage and frequency of each med
· Laboratory – List names of labs/tests and results.
You will submit one data packet that contains two concept maps
Certainly! Below is a structured outline for creating a data packet with two concept maps, based on the instructions you provided.
### Cover Page
– **Title:** Data Packet: Concept Maps
– **Name:** [Your Name]
– **Course Number:** [Course Number]
– **Due Date:** [Due Date]
—
### Concept Map 1
#### Main Medical Problem:
– **Diagnosis for Admission:** Congestive Heart Failure (CHF)
#### Medical History:
– Hypertension (HTN)
– Coronary Artery Disease (CAD)
– Diabetes Mellitus (DM)
– Asthma
– Pneumonia
– Surgeries: CABG (Coronary Artery Bypass Graft) in 2015, Appendectomy in 2008
#### Present/Current History:
– Recent CHF exacerbation with symptoms of dyspnea, orthopnea, and edema.
– Hospitalized for acute decompensated heart failure.
– Current treatments: Diuretics, ACE inhibitors, Beta-blockers, Insulin for DM, Inhalers for asthma.
### Nursing Diagnosis 1:
– **NANDA Diagnosis:** Fluid Volume Excess related to compromised regulatory mechanisms as evidenced by edema, dyspnea, and orthopnea.
#### NOC Statement:
– **Overall Goal:** The patient will maintain optimal fluid balance as evidenced by decreased edema and stable weight.
#### Goals:
- **Short Term Goal:** The patient will have a reduction in peripheral edema within 48 hours.
- **Short Term Goal:** The patient will maintain stable vital signs within 24 hours.
- **Long Term Goal:** The patient will demonstrate understanding of fluid restriction guidelines and adhere to them within one week.
#### NIC Statement and Interventions:
- **Intervention for Goal 1:**
– **Action:** Administer prescribed diuretics.
– **Rationale:** Diuretics help reduce fluid overload by increasing urine output.
– **Citation:** [Reference Source]
- **Intervention for Goal 2:**
– **Action:** Monitor vital signs every 4 hours.
– **Rationale:** Regular monitoring helps detect changes in condition early.
– **Citation:** [Reference Source]
- **Intervention for Goal 3:**
– **Action:** Educate the patient on fluid restriction and daily weight monitoring.
– **Rationale:** Understanding and adhering to fluid restriction can prevent fluid overload.
– **Citation:** [Reference Source]
#### Evaluation:
- **Evaluation for Goal 1:**
– Goal met. Edema reduced as evidenced by a decrease in ankle circumference.
– Continue current diuretic therapy.
- **Evaluation for Goal 2:**
– Goal met. Vital signs stable within the monitored period.
– Continue regular monitoring.
- **Evaluation for Goal 3:**
– Goal not met. Patient needs further education on fluid restriction.
– Provide additional teaching and educational materials.
—
### Concept Map 2
#### Main Medical Problem:
– **Diagnosis for Admission:** Congestive Heart Failure (CHF)
#### Medical History:
– Same as Concept Map 1.
#### Present/Current History:
– Same as Concept Map 1.
### Nursing Diagnosis 2:
– **NANDA Diagnosis:** Activity Intolerance related to imbalance between oxygen supply and demand as evidenced by fatigue and dyspnea on exertion.
#### NOC Statement:
– **Overall Goal:** The patient will demonstrate improved tolerance to activity as evidenced by the ability to perform ADLs without dyspnea.
#### Goals:
- **Short Term Goal:** The patient will verbalize understanding of energy conservation techniques within 24 hours.
- **Short Term Goal:** The patient will exhibit improved endurance to perform ADLs with minimal assistance within 3 days.
- **Long Term Goal:** The patient will participate in a cardiac rehabilitation program within one month.
#### NIC Statement and Interventions:
- **Intervention for Goal 1:**
– **Action:** Teach the patient energy conservation techniques.
– **Rationale:** Energy conservation techniques help manage fatigue and improve activity tolerance.
– **Citation:** [Reference Source]
- **Intervention for Goal 2:**
– **Action:** Assist the patient with ADLs and gradually increase activity level.
– **Rationale:** Gradual increase in activity helps improve endurance.
– **Citation:** [Reference Source]
- **Intervention for Goal 3:**
– **Action:** Refer the patient to a cardiac rehabilitation program.
– **Rationale:** Cardiac rehab provides structured exercise and education to improve cardiovascular health.
– **Citation:** [Reference Source]
#### Evaluation:
- **Evaluation for Goal 1:**
– Goal met. The patient accurately verbalized energy conservation techniques.
– Reinforce teaching as needed.
- **Evaluation for Goal 2:**
– Goal partially met. The patient shows improvement but still requires assistance for some ADLs.
– Continue gradual increase in activity level.
- **Evaluation for Goal 3:**
– Goal not met. Patient has not yet enrolled in cardiac rehabilitation.
– Follow up with referral and encourage participation.
—
### Additional Information:
#### Medications:
– Diuretics (e.g., Furosemide 40 mg PO daily)
– ACE Inhibitors (e.g., Lisinopril 10 mg PO daily)
– Beta-blockers (e.g., Metoprolol 50 mg PO BID)
– Insulin (e.g., Insulin glargine 10 units SC daily)
– Inhalers (e.g., Albuterol inhaler PRN)
#### Laboratory Results:
– CBC: WNL (Within Normal Limits)
– BMP: Elevated BUN and Creatinine
– EKG: Shows signs of left ventricular hypertrophy
– BNP: Elevated, indicating heart failure exacerbation
—
### References
– [Your sources here in APA 7th edition format]
—
This outline provides a structured approach to creating your data packet with concept maps, nursing diagnoses, goals, interventions, rationales, and evaluations. Be sure to adapt and expand upon this template to fit your specific patient data and clinical findings.
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