metastatic cancer
Building upon the learning process for planning care through care mapping in NSG 110 and NSG 120, each student will create at least one care map in each clinical.
Select the patient from the clinical rotation and obtain approval from your clinical instructor to assure this patient is appropriate for the care mapping assignment.
Using the Care Map Template create a plan of care map of a select patient. Students’ name must be on the care map and the write up of the questions.
Steps in care mapping (each section shall include the complete and accurate patient information):
Identify the patient’s medical diagnosis, problem, or reason for seeking health/medical care. (By week 4)
Medical Diagnosis A description of the problem or reason for seeking care.
This portion should include:
pathophysiology-include a description of what the disease process is, who does it affect and when, where does it affect them and why it affects them (risk factors)
signs and symptoms of the disease/disorder
how the disease/disorder is diagnosed
and typical treatment (medical and surgical)
Nursing Assessment. This is the patient assessment by the student nurse and it comes from a variety of sources:
History and Physical Assessment Findings:
History: Genitourinary:
Neuro/Sensory/Mental Status: Gastrointestinal:
HEENT: Integumentary:
Cardiac: Musculoskeletal:
Respiratory: Reproductive:
Emotional/Social/Spiritual:
***Physical assessment should involve inspection, auscultation, palpation & percussion.
Laboratory and diagnostic tests
Pharmacologic therapies in a table: (Medication name, individualized indications, dose, route, frequency, time, top three side effects pertinent to the medication, contraindications, if any)
Assessment Analysis – Analyze the data gathered (learned in NSG 110):
Cluster the data into patterns and identify the Gordon’s Functional Health Patterns. Indicate whether the pattern is functional or dysfunctional.
Determine Associate Nursing Diagnoses based upon the Selected Gordon’s Patterns
Identify nursing diagnoses (problems that represent the patient’s responses to the medical diagnosis).
Nursing Diagnosis (NANDA)
Related to (what factors are causing the problem) _______________________________
As evidenced by (assessment findings- the evidence that a problem is occurring)
***Reminder to review the parts of a Problem-Oriented diagnosis, a Risk diagnosis, and a Health Promotion diagnosis.
Select the Priority Problems in each Category : Physiological, Psychosocial and Educational needs (only NSG 315 and NSG 430)
Develop plans of care in the appropriate template to alleviate the problems Each plan must have the following:
an appropriate nursing diagnosis,
patient-centered goal statement,
Patient-centered SMART outcomes,
evidence-based interventions,
and evaluation criteria.
