Gathering Clinical Data: The framework for concept map care plan

1. 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 94-7-12

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

3. 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.

4. 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

5. 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 Patient profile database

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

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

10. 生前預立遺囑 法定醫療代理人 DNR

12. 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

13. Component: Treatment • Sources: Chart, Kardex • Record treatments, support services (ie. PT, OT, ST, RT, SW), consultations • 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

14. 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

15. Component: Elimination • Sources: Chart, flow sheet • Bowel • Last bowel movement • Problems: constipation, diarrhea, flatus, incontinence, belching • Bladder • 24-hour urine output • On Foley/condom catheter • Problems: hesitancy, frequency, burning, incontinence, odor • Other • 由評估結果連結到個案的健康問題 concept map care plan

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

17. 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

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

19. 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? Remarks

20. Time out! Wake up!!