Putting Practice to Words

1. Putting Practice to Words Concept Mapping, Care Planning, & APA Formatting Ryan Rickley, SN Mentor Student Nurse National University

2. Objectives • Identify the proper use of concept mapping, as a means to deconstruct complicated ideas • Explain proper care planning technique – from conceptualization to evaluation • Discuss APA formatting and resources for help

3. Practice into Words Concept Mapping Breaking down & relating complex ideas.

4. Concept Map • Takes complicated ideas and breaks them down • Allows you to see relationships between seemingly separate ideas • Helps to develop clinical judgment skills • Allows for prioritization, and elimination of data • When lost, start by mapping out your ideas, thoughts, experiences – it can guide you to the priorities

5. The Concept Map

6. The Concept Map

7. Practice Activity is an 88-year-old woman who presented with complaints of nausea, vomiting, and abdominal pain. Her vital signs on admission are temperature 99.6°F (37.6°C), blood pressure 145/90, pulse 125, and respiratory rate 24. Her laboratory tests reveal white blood cell count (WBC) 13,000/mm3, potassium (K+) 3.2 mEq/L, lipase 449 units/L, amylase 306 units/L, total bilirubin 3.4 mg/dL, direct bilirubin 2.2 mg/dL, aspartate aminotransferase (AST) 142 U/L, and alanine aminotrans- ferase (ALT) 390 U/L. Physical examination reveals a distended abdomen that is very tender on palpation. Bowel sounds are present in all four quadrants, but hypoactive. Mrs. Miller is admitted with a diagnosis of acute pancreatitis. She will be kept nothing by mouth (NPO). Intravenous (IV) fluid of D51/2 NS with 40 mEq of potassium chloride (KCl) per liter at 100 mL per hour is prescribed. The health care provider prescribes continued administration of her preadmission medica- tions, that is, pantoprazole sodium and levothyroxine sodium (in IV form because the client is NPO) and spironolactone (available in oral form), and adds the pre- scription of IV metoclopramide and morphine sulfate. A nasogastric (NG) tube is inserted and attached to low wall suction. Mrs. Miller’s NG tube is draining yellow-brown drainage. Her pain is being man- aged effectively with IV morphine 4 mg every four hours. Mrs. Miller is anxious and has many questions for the nurse: “What is the test I am having done today? What is pancreatitis? Will I need to have surgery? Why did they put this tube in my nose? When will I be able to eat real food?” 

8. Practice into Words Care Planning Guiding your practice with evidence.

9. Care Plans • Are prioritized based on the client condition • Incorporate data gathered from assessment, patient chart, labs, etc. • Are SMART at every step • Formatted using APA • Speak to your practice – not a textbook’s • Convey what you did, will do, or should do for the patient to guide them towards wellness

10. Assessment Which data is important? (select all that apply) • Medical Diagnosis from Chart • Physical Findings from Assessment • Psychosocial Findings from Assessment • Suspected Problems/Issues from Assessment

11. Assessment • It’s a trick question: WE Look at EVERYTHING!!! • Ensure that your ASSESSMENT data is in your: • Diagnosis • Goals • Evaluations • Assessment data really doesn’t belong in Interventions

12. Diagnosis • NANDA • ALWAYS use a NANDA. NEVER MAKE UP YOUR OWN! • Prioritize • WHICH problem is of greatest concern? • WHICH problem did you do the most work around? • WHICH problem requires the most re-assessment? • WHICH priority framework SUPPORTS your choice? • WHEN in doubt.. • ABC’s or Maslow’s will guide your decision making

13. Prioritizing: ABC’s • Airway • Ineffective Airway Clearance • Breathing • Ineffective Breathing Pattern • Impaired Gas exchange • Inability to sustain spontaneous ventilation • Circulation • Altered Tissue Perfusion • Decreased Cardiac Output • Fluid Volume Excess

14. MASLOWS Hierarchy of Needs

15. Prioritizing: MHON • Physiological Needs: Food, Water, Warm, Rest • Fluid Volume Deficit • Imbalanced Nutrition • Ineffective Thermoregulation • Ineffective Sleeping Pattern • Physiological Needs: Safety • Impaired Skin Integrity • RISK Diagnosis START here! • Risk for: Injury, Falls, Infection, Body Temp, Aspiration

16. Let’s Talk about RISK • IF it’s a risk Dx, then: • IT HAS NOT HAPPENED YET! • You CANNOT have EVIDENCE (NO AEB!!) • It CANNOT be the priority • UNLESS…. • Use THOUGHTFULLY! Probably not the most important.

17. When use risk? Maybe use as a 3rd or 4th Dx… or in well-patients (I.E. OB): • Risk for Falls • Risk for Impaired Skin Integrity • Risk for Aspiration “Lame” Risk Dx: • Risk for Injury • Risk for Infection • Risk for Pain Can anyone tell me WHY these are “Lame”? Answer: Everyone is at risk for these things in the hospital.

18. Let’s write a Dx • Priority NANDA Diagnosis • R/T: disease processes, &/or suspected processes, &/or “the problem” • AEB • Think of this as “making your case” that you are correct in your diagnosis. Your diagnosis needs clinical support

19. Example Dx Good: Ineffective gas exchange R/T pulmonary edema secondary to fluid volume overload d/t CHF AEB crackles bilaterally upon auscultation, ABG abnormalities (7.32, 50, 22), SPO2 91% on 6L per NC, BLE pulses +4, patient complaints of shortness of breath, difficulty breathing, and “feeling like their drowning” Bad: Ineffective gas exchange R/T problems breathing AEB low o2 levels, CHF, and crackles in their lungs

20. How do you get the R/T? Think: WHAT can cause this problem to occur? Use a concept map to look for the root-cause of the problem. If they can’t breath – WHY? If their o2 SATS are low – WHY? If their pulses are bounding – WHY? This will get you to your R/T – the medical diagnosis should confirm your results, not be your result

21. How do you get the AEB? YOUR ASSESSMENT DATA! • Physical Assessment • Psychosocial Assessment • Patient Complaints • Medical Records / LAB data • GET IT ALL!! The more assessment data, the stronger your case.

22. Practice Activity Pair in groups of 2-3 1 minute Formulate your PRIORITY Dx

23. Goals • SMART GOALS • Specific: What is success? • Measureable: How will you evaluate? • Achievable/Realistic: Can you do it? • Timely: WHEN will your goal be evaluated?

24. Goals • Short-Term • END of shift (as defined by..) • Very tangible • Long-Term • End of week, by discharge, etc. • (definite point in time still)

25. SMART • Specific • Patient will experience no seizure activity • Measureable • AEB absence of tonic-clonic events • AR • Yes, because nursing can control seizures with interventions (we don’t write this part…) • Timely • Through end of shift (1900).

26. Put it together • Patient will be free of seizure activity AEB absence of tonic-clonic events through end of shift (1900). vs. • Patient will not experience any seizures during my shift.

27. Practice Activity Pair in groups of 2-3 1 minute Formulate your PRIORITY GOAL for Dx

28. Interventions • THEY ARE WHAT YOU DID or WOULD do! • They should be SPECIFIC • They should be TIMELY • They should be MEASUREABLE • Seeing a pattern?  • Always include a rationale with your intervention.

29. Strong vs. Weak • Weak • Copying from the book • Saying things you would never do • Pulling stuff out of your, you know what • Strong • Real interventions that will impact the goal, and guide the client towards wellness • Something that you really did, or would do. • Something that would make the biggest improvement in the patient condition • You prioritize these as well, based on MOST helpful, to least helpful and/or least critical

30. Interventions • Infuse Magnesium Sulfate @ 125mL/hr per MD orders. Mg will prevent seizure activity by increasing the threshold of CNS activity. • Monitor VS/Neuro Vitals Q1H. S/Sxof impending seizures including ALOC, visual disturbances, and headaches, which would warrant further internvetion. • Monitor client for mag toxicity. S/SX including RR depression AEB <10 RR/min, Dysreflexia AEB Reflexes > or < +2, all indicate a critical change in condition. • Implement and maintain seizure precautions including padded bed rails, bed down, call light in reach, all ambulation with nursing assist, and bed alarm. Safety is the priority and responsibility of the nurse.

31. Practice Activity Pair in groups of 2-3 1 minute Formulate your PRIORITY Interventions for Dx

32. Evaluations • Guess what? • They should be SPECIFIC • They should be TIMELY • They should be MEASUREABLE • This is your chance to reflect on your practice, and recommend how to move forward with the care of this patient. • They should evaluate your interventions – did it work? Did your patients condition: • Improve • Worsen • Stay the Same

33. Evaluations/Outcomes • The short-term goal was not achieved as per evaluation at 1730. Although the interventions were implemented, the patient still displays the same s/sxof ineffective tissue profusion and requires reevaluation and new interventions that attempt to better address the patient’s needs. • The long-term goal cannot be evaluated at this time, however the nursing team should evaluate the effectiveness of their interventions based upon the results of ongoing assessment of the patient. The nurse should continue to advocate for the patient and work with the interdisciplinary team to identify treatment interventions that address the underlying medical conditions.

34. Practice Activity Pair in groups of 2-3 1 minute Formulate your Evaluation Statements

35. APA & Sources American Psychological Association Formatting

36. Journals • Are not scary! • You need them to legitimize your work. • They are your evidence to base your practice • Only peer reviewed-journals • Nursing sources are always preferred • Recent is always better (Past 5 years) • Use the library – it has great resources and saves you a lot of time • Check the automatic citations for errors

37. General Considerations Running Head + Page Number in Header Title Page Headings In-text citations 2 spaces after each sentence NO spaces between paragraphs Double spaced – 12 point fonts 1 Inch Margins ALL sides References Page

38. Running Head – 1st Page • Running Head: TITLE OF RUNNING HEAD • NO MORE THAN 50 characters TOTAL • Running Head = normal capitalization • TITLE IS ALL CAPS • “Running Head” is ONLY on title page

39. Title Page Title Subtitle Name School

40. Second Page(first page of paper) Running Head (All CAPS – doesn’t say running head) Restate the title (center, NOT bold) Start the paper with your introduction All paragraphs have a .5 inch indent, but no spacing between paragraph ALWAYS USE HEADINGS to guide the reader • NOTE: THERE IS NOT an “Introduction” Header!!

41. Title Page

42. Second Page(first page of paper)

43. Headings

44. Listing Facts

45. Listing Facts

46. In-Text Citations • 1 Author: (Author, Year) • 1 Author + Page (Author, Year, p. #) • Up to 3 Authors: (Author, Author, & Author, Year) • More than 3 Authors: (Author et al., Year) • Rickley (2013) states that effective in-text citations are utilized this way.

47. In-Text Citations • 1 Author: (Author, Year) • 1 Author + Page (Author, Year, p. #) • Up to 3 Authors: (Author, Author, & Author, Year) • More than 3 Authors: (Author et al., Year) • Rickley (2013) states that effective in-text citations are utilized this way.

48. In-Text Citations

49. Reference List • Listed alphabetical by author/organizations • Title center, not bolded • Hanging indent on second line • When referring to books, chapters, articles, or Web pages, capitalize only the first letter of the first word of a title and subtitle, the first word after a colon or a dash in the title, and proper nouns. • Do not capitalize the first letter of the second word in a hyphenated compound word. • Maintain capitalization of journal title, or book title

50. Reference List