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.)

Flowchart: Process:  Cardiac


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.
Flowchart: Process: Elimination
•	Foley
•	Enlarged Prostate
•	Proscar
Flowchart: Process: Breathing/Oxygenation
•	Ca of lung (history)
•	Radiation/chemotherapy (history)
•	Decreased breath sounds, right lower lung
•	Oxygen @ 6L by face mask
Flowchart: Process: Mobility
•	Ca of bone (history)
•	Fall Protocol
•	Tubes (tripping)


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: Monitor breath sounds q4hCheck VS, esp resp q4h   Do CDB & ISMaintain O2 mask in placeAssess O2 Sat q4hMonitor HgbAdminister VenotlinPatient Responses: Decreased breath sounds R lower lung field8am: 128/78, HR112. R20, 100F (orally) Noon: 130/76, HR96, R20, 98.4F (orally) Done q2h, non-productive and weak coughIn place except for breakfast8am 96%, noon 96%Not available10am 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: Check VS q4h, esp BP & HR   Apical pulse check prior to Digoxin administrationCheck Potassium levelAssess mental statusAssess urine outputAssess peripheral pulsesPatient Responses: 8am: 128/78, HR 112, R 20, 100F (orally) Noon: 130/76. HR 96, R 20, 98.4F(orally) 112/min at 10am   3.   K=3.9 A&O x 3> 30 mL/hAll +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: Assess new lab valuesAssess I&ONPOMouth careMonitor N/G tube, check drainageAssess FBSAssess bowel sounds Assess for distentionAssess drainage from drainsPatient Responses: Electrolytes WNL (Na, K,)For 6 hours: Intake 600mL/ Output 650 mLNPO except for ice chipsGood oral hygiene, no sordesPatent, draining bile colored fluid (75mL)109 at 10amHypoactiveNone, soft abdomenPurulent 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: Assess pain levelAssess patency of PCA linePositioningCheck noise, lightingBackrubPatient Responses: Pain level 2-3Patent linePositioned on side with a pillowDecreased light, patient fell asleepStated 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: Monitor temp q 4hAssess WBCBed bath   Check skin integrityFoley careOral careAssess wounds, drains     8. Administer KefzolPatient Responses: T 100F at 8am, 98.4F at 12noonWBC 12,000Cooperated, but did not like being touched – it hurtNo signs of breakdown, Decubitus Risk: 17Patent, skin pink and intactGood oral hygiene, no sign of infectionDressing changed by physician, skin edges approximated with sutures, erythematous, dry; drain purulent yellow, foul smellingGiven IV at 10am
Evaluation: Wound intact, drainage from drains is purulent, temp is WNL

Order a similar paper and get 15% discount on your first order with us

Dr. Padma Myers
Dr. Padma Myers
98% Success Rate
Read More
“Hello, I deliver nursing papers on time following instructions from the client. My primary goal is customer satisfaction. Welcome for plagiarism free papers”
Stern Frea
Stern Frea
98% Success Rate
Read More
Hi! I am an English Language and Literature graduate; I have written many academic essays, including argumentative essays, research papers, and literary analysis.
Dr. Ishid Elsa
Dr. Ishid Elsa
98% Success Rate
Read More
"Hi, count on me to deliver quality papers that meet your expectations. I write well researched papers in the fields of nursing and medicine".
Dr. Paul P. Klug
Dr. Paul P. Klug
99% Success Rate
Read More
"A top writer with proven reliability and experience. I have a 99% success rate, overall rating of 10. Hire me for quality custom written nursing papers. Thank you"

How Our Essay Writing Service Works

Tell Us Your Requirements

Fill out order details and instructions, then upload any files or additional materials if needed. Then, confirm your order by clicking “Place an Order.”

Make your payment

Your payment is processed by a secure system. We accept Mastercard, Visa, Amex, and Discover. We don’t share any informati.on with third parties

The Writing Process

You can communicate with your writer. Clarify or track order with our customer support team. Upload all the necessary files for the writer to use.

Download your paper

Check your paper on your client profile. If it meets your requirements, approve and download. If any changes are needed, request a revision to be done.

Recent Questions

Stay In Touch!

Leave your email and get discount promo codes and the best essay samples from our writers!
Chat with us
WhatsApp Your Assignment!
Hello! Welcome! We have writers online to help you at any time!