Gathering Clinical Data: The framework for concept map care plan 分享者：林淑媛、邱啟潤、陳季員、王美嬅

Gathering assessment data is the most important thing that student nurses do.

Importance  Good clinical judgments are based on accurate and complete data collection.  Purpose of this section: To provide guidelines for collecting relevant clinical data.  Objective: To decrease overwhelmed feeling about collecting data. To promote student ’ s ability to make good clinical judgment.

Finding important data  Reference and responsible persons: Student nurses, clinical faculty, nursing staff  Where to look for data? Many students are not familiar with data sources. Many students cannot read the writing or understand the abbreviations.  Data are everywhere!! Just have to find it! Solution. ….Patient profile database

Patient profile database  Characteristics: The database has physical, psychological, social, and cultural components. 99% of data can be collected from patient notes and records; 1% from conversations with patients and the assigned nurse.  Components of the patient profile database

Erickson- 8-stage human growth theory Life span On or off the expected course of treatment

All medical problems must be identified and defined. (Kardex & Chart) Abbreviations & poor handwriting is a common problem Surgical consent & Kardex (different)

生前預立遺囑 法定醫療代理人 DNR

Component: Medication  Sources: Chart, Kardex, Medication record 6 rights  Drug, patient, dose, route, time right, right to refuse a medication. Other: Allergies, pain medications  pain rating  由藥物類別、作用連結到個案的健康問題  concept map care plan

Component: Treatment Sources: Chart, Kardex 1. Record treatments, support services (ie. PT, OT, ST, RT, SW), consultations 2. IV therapy (type/rate, IV site, other)  Know why the patient is receiving the treatment  由治療作用連結到個案的健康問題  concept map care plan

NPO, Liquid, Soft, Low-fat, Low sodium, DM diet etc. 由評估結果連結到 個案的健康問題  concept map care plan

Component: Elimination  Sources: Chart, flow sheet 1. Bowel 1. Last bowel movement 2. Problems: constipation, diarrhea, flatus, incontinence, belching 2. Bladder hour urine output 2. On Foley/condom catheter 3. Problems: hesitancy, frequency, burning, incontinence, odor 3. Other  由評估結果連結到個案的健康問題  concept map care plan

Component: Activity Sources: Kardex, flow sheet 1. Ability to walk 2. Type of activity orders (different!) 3. Use of assistive devices 4. Fall-risk assessment rating 5. Side rails 6. Restraints 7. Weakness 8. Trouble sleeping  由評估結果連結到個案的健康問題  concept map care plan

Physical Assessment Data: BP, TPR, BH, BW, Neurological/mental status, musculoskeletal system, cardiovascular system, respiratory system, gastrointestinal system, skin and wounds, eyes, ears, nose, throat

Psychosocial-cultural component and additional information  Sources: Chart, Nursing notes 1. Religious preference 2. Marital status 3. Health-care benefits and insurance 4. Occupation 5. Emotional state  Additional information Assessment- Fall risk, pressure ulcer, skin Standardized nursing care plans Clinical pathway Patient education materials

Remarks Conclusions Patient profile database is comprehensive and systematic 由評估結果連結到個案的 健康問題  concept map care plan  Obstacles Time consuming Completeness undetermined Inappropriate linkage to health problems Unreachable sources What else?

Time out! Wake up!!