Nursing Implementation: Using Concept Map Care Plans in the Health-Care Agency 楊麗玉金繼春

Concept Map Care Plan An organizational tool for clinical data An organizational tool for clinical data Update the plan to account for dynamic changes Update the plan to account for dynamic changes Step ： Step ：  Getting organized  Clinical preconference  Updating assessments, reporting findings, giving medications  To facilitate communication  Implementing and evaluating care

Getting Organized Use red pen to write updates differently on the diagram Use red pen to write updates differently on the diagram Check medication records Check medication records Routine and p.r.n. Routine and p.r.n. Check IV administration records Check IV administration records Highlight the IV fluid and rate Highlight the IV fluid and rate Check treatments Check treatments Update and write treatments in Update and write treatments in Appropriate nursing diagnosis box Appropriate nursing diagnosis box Make a new diagnostic box Make a new diagnostic box A corner box A corner box

Getting Organized (cont.) Check laboratory data Check laboratory data For completed test: Find the reports and For completed test: Find the reports and write the results write the results For pending result: Write the name of the For pending result: Write the name of the test, place a blank test, place a blank Obtain information from the previous shift Obtain information from the previous shift

Clinical Preconference The purpose is for clinical faculty to review the plans of care including have collected, correctly analyzed, categorized data, goals, outcomes, interventions The purpose is for clinical faculty to review the plans of care including have collected, correctly analyzed, categorized data, goals, outcomes, interventions Prepared to orally address questions concerning the plan: assessment data, ND, goals, outcomes, interventions, and rationales Prepared to orally address questions concerning the plan: assessment data, ND, goals, outcomes, interventions, and rationales

What to do after updating the care plan Performing patient assessment Performing patient assessment Wake patient to do first assessment Wake patient to do first assessment Write findings in the evaluation column Write findings in the evaluation column Reporting assessment data Reporting assessment data To patient’s assigned staff nurse To patient’s assigned staff nurse To clinical faculty To clinical faculty Interrupt them to report the abnormality Interrupt them to report the abnormality Finding medications Finding medications

To facilitate communication Bedsides communication Bedsides communication Bedside rounds Bedside rounds Faculty comments appear on map in a distinct color, ex: purple or green Faculty comments appear on map in a distinct color, ex: purple or green Reporting off the unit Reporting off the unit

Implementing and evaluating care Establish mutual goals, expected outcomes, and schedule of activities Establish mutual goals, expected outcomes, and schedule of activities Evaluate and record the patient’s responses in red ink Evaluate and record the patient’s responses in red ink Evaluation of the teaching plan Evaluation of the teaching plan Teaching methods Teaching methods Responses of the patient Responses of the patient Knowledge gained by the patient Knowledge gained by the patient Evaluate outcomes against standardized care plans and clinical paths. Evaluate outcomes against standardized care plans and clinical paths.