Urinary Case Study

NURSING PROCESS PAPERS: CONCEPT MAPPING

The Nursing Process: Assessment, Nursing Diagnosis, Goals, Interventions, and Evaluation.

PREPARATION: ASSESSMENT PHASE.
• Gather clinical data: assess the patient; review the patient records, laboratory data, medications, and treatments. Objective and subjective data are important.

STEP 1: DEVELOP A BASIC SKELTON DIAGRAM (See Example #1)
• Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care.
• In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis).
• Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses – actual or potential – to this reason for seeking health care (usually the medical diagnosis).
• Recognize major problem areas. (You do not have to state the nursing diagnosis yet.)

STEP 2: ANAYZE & CATEGORIZE THE DATA (See Example #2)
• Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses.
• Data can be listed in more than one area if it is relevant to more than one category.
• If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor.
• Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map.

STEP 3: ANALYZE NURSING DIAGNOSES RELATIONSHIPS (See Example #3)
• Draw lines between nursing diagnoses to indicate relationships.
• Label the general problems you have identified according to the North American Diagnosis Association (NANDA) classification system.

STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS (See Example #4)
• On a separate piece of paper, for each nursing diagnosis write your patient goals/outcomes.
• Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …”
• List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are carefully monitoring, treatments, patient education, and medications.
• Be complete and think, “What am I doing this day for this patient/client”.
• Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day.

STEP 5: EVALUATE PATIENT’S RESPONSES (See Example #4)
• As you complete a nursing intervention, write down the patient’s responses.
• This step also involves writing your clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about. Did you meet the goal or not?

SAMPLE PATIENT for Nursing Process Paper: Concept Mapping

Your patient for today is W. C., a 76-year-old male who was admitted 4 days ago with an abdominal abscess and bowel obstruction. He went to the operating room for an Exploratory Laparotomy two days ago.
He has a history of DM Type 2, Cancer of the lung 2 years ago that was treated with radiation and chemotherapy, an enlarged prostrate, Cancer of the bone with chronic bone pain in his right leg, and Atrial Fibrillation with a pulse rate of 128 and irregular.

He has 2 abdominal drains with purulent drainage and a temp of 100.5 F. Currently he is NPO with a NG tube to suction. He has an IV of D5 RL at 100 mL/hr. He has decreased breaths sounds on the right lower lung field and is on Oxygen at 6L by mask. He has a Foley catheter in place.
He says he is nervous; clenching his fists, and says that he is afraid of dying.

Medications: PCA with Morphine, Digoxin, Kefzol, Ventolin inhaler, Proscar, and Regular Insulin by sliding scale.

STEP 1: DEVELOP A BASIC SKELETON DIAGRAM (Example #1)
• Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care.
• In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis).
• Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses to this reason for seeking health care (usually the medical diagnosis).

Recognize major problem areas. (You do not have to state the nursing diagnosis yet.)

STEP 2: ANALYZE & CATEGORIZE THE DATA (Example #2)
• Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses.
• Data can be listed in more than one area if it is relevant to more than one category.
• If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor.
• Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map.

Solid lines are definite relationships
Dotted lines are possible relationships

STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS
(Example #4)
• On a separate piece of paper, for the top three priority nursing diagnosis write your patient goals/outcomes.
• Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …”
• List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are supposed to be carefully monitoring, treatments, patient education, and medications.
• Be complete and think, “What am I doing this day for this patient/client”.
• Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day.

STEP 5: EVALUATE PATIENT’S RESPONSES (Example #4)
• As you complete a nursing intervention, write down the patient’s responses.
• This step also involves writing you clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about.

Problem/Nursing Diagnosis #1: Impaired Gas Exchange
Goal/Outcome: The patient will maintain an oxygen saturation > 95%
Nursing Interventions:
1. Monitor breath sounds q4h
2. Check VS, esp resp q4h

3. Do CDB & IS
4. Maintain O2 mask in place
5. Assess O2 Sat q4h
6. Monitor Hgb
7. Administer Venotlin Patient Responses:
1. Decreased breath sounds R lower lung field
2. 8am: 128/78, HR112. R20, 100F (orally)
Noon: 130/76, HR96, R20, 98.4F (orally)
3. Done q2h, non-productive and weak cough
4. In place except for breakfast
5. 8am 96%, noon 96%
6. Not available
7. 10am as ordered
Evaluation: Breathing nonlabored, cooperative with treatments but cough is very weak. O2 sat remains > 95%

Problem/Nursing Diagnosis #2: Decreased Cardiac Output
Goal/Outcome: The patient will maintain a BP and HR WNL
Nursing Intervention:
1. Check VS q4h, esp BP & HR

2. Apical pulse check prior to Digoxin administration
3. Check Potassium level
4. Assess mental status
5. Assess urine output
6. Assess peripheral pulses Patient Responses:
1. 8am: 128/78, HR 112, R 20, 100F (orally)
Noon: 130/76. HR 96, R 20, 98.4F(orally)
2. 112/min at 10am

3. K=3.9
4. A&O x 3
5. > 30 mL/h
6. All +2
Evaluation: BP remains stable, PR continues to be elevated – continue with assessments and Digoxin administration as ordered

Problem/Nursing Diagnosis #3: Risk for fluid volume deficit
Goal/Outcome: The patient’s N/G tube and drains will remain patent, and the I&O will balanced
Nursing intervention:
1. Assess new lab values
2. Assess I&O
3. NPO
4. Mouth care
5. Monitor N/G tube, check drainage
6. Assess FBS
7. Assess bowel sounds
8. Assess for distention
9. Assess drainage from drains Patient Responses:
1. Electrolytes WNL (Na, K,)
2. For 6 hours: Intake 600mL/ Output 650 mL
3. NPO except for ice chips
4. Good oral hygiene, no sordes
5. Patent, draining bile colored fluid (75mL)
6. 109 at 10am
7. Hypoactive
8. None, soft abdomen
9. Purulent yellow, foul-smelling
Evaluation: Tubes and drains are patent, output is 50 mL > intake, and electrolytes are WNL,

Problem/Nursing Diagnosis #5: Pain
Goal/Outcome: The patient’s pain level will remain at 3 or below during this shift
Nursing Interventions:
1. Assess pain level
2. Assess patency of PCA line
3. Positioning
4. Check noise, lighting
5. Backrub Patient Responses:
1. Pain level 2-3
2. Patent line
3. Positioned on side with a pillow
4. Decreased light, patient fell asleep
5. Stated it hurt to be touched
Evaluation: Morphine by PCA is controlling the pain at a 2-3 level, positioning and decreasing the lighting (non-pharmacological measures) were helpful.

Problem/Nursing Diagnosis #6: Infection
Goal/Outcome: Patient’s temperature will be WNL within 24 hurs
Nursing Interventions:
1. Monitor temp q 4h
2. Assess WBC
3. Bed bath

4. Check skin integrity
5. Foley care
6. Oral care
7. Assess wounds, drains

8. Administer Kefzol Patient Responses:
1. T 100F at 8am, 98.4F at 12noon
2. WBC 12,000
3. Cooperated, but did not like being touched – it hurt
4. No signs of breakdown, Decubitus Risk: 17
5. Patent, skin pink and intact
6. Good oral hygiene, no sign of infection
7. Dressing changed by physician, skin edges approximated with sutures, erythematous, dry; drain purulent yellow, foul smelling
8. Given IV at 10am
Evaluation: Wound intact, drainage from drains is purulent, temp is WNL