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

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 car

e plan

Component: Elimination Sources: Chart, flow sheet1. Bowel

1. Last bowel movement2. Problems: constipation, diarrhea, flatus, incontinence, belchin

g2. Bladder

1. 24-hour urine output2. On Foley/condom catheter3. 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 walk2. Type of activity orders (different!)3. Use of assistive devices4. Fall-risk assessment rating5. Side rails6. Restraints7. Weakness8. 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 notes1. Religious preference2. Marital status3. Health-care benefits and insurance4. Occupation5. 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!!