Standardized Care Map Essay
NANDA Nursing Diagnoses
- Acute Pain
- Impaired Skin Integrity
- Ineffective Airway Clearance
Standardized Language and Data Element Sets
- Acute Pain:
NANDA-I: Acute Pain
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SNOMED CT: Acute pain (finding)
LOINC: Pain severity (assessment)
- Impaired Skin Integrity:
NANDA-I: Impaired Skin Integrity
SNOMED CT: Disorder of skin (disorder)
LOINC: Skin integrity (assessment)
- Ineffective Airway Clearance:
NANDA-I: Ineffective Airway Clearance
SNOMED CT: Ineffective airway clearance (finding)
LOINC: Breathing status (assessment)
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Nursing Care Plan
| Assessment | Nursing Diagnosis | Goal and Outcome criteria | Intervention | Rationale | Implementation | Evaluation |
| Subjective data
Patient rating of pain at 9 on a scale (of 0-10). The patient verbalizes pain. Objective data Grimace.
|
Acute pain related to inflammation of the lung parenchyma as evidenced by the patient verbalizing and rating pain and the patient having facial grimace. | Goal
To relieve pain within 4 hours. Outcome criteria The patient is to verbalize reduced pain; the patient is to rate the pain at 3 on a pain scale of 0-10, and the patient is to stop grimacing. |
Administer analgesics i.e., Diclofenac 75 mg.
Non-pharmacological pain management, e.g., warm compresses, Guided imagery, or relaxation techniques |
Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) used to manage pain. It works by blocking the production of substances in the body that cause pain and inflammation (Alfaro & Modi, 2020).
Warm compresses decrease inflammation and numb the area. Guided imagery or relaxation techniques reduce pain by helping the person to focus on something other than the pain and by releasing endorphins which can help to block pain signals. |
Diclofenac 75 mg administered.
The magazine was issued to the patient at 9.00 Am. |
The patient reports pain has subsided.
The patient rates pain at 2. Patients do not grimace. The goal was fully met, but the patient remained susceptible to pain. Continue the prescribed analgesia. |
| Subjective data
The patient reports apnea, dyspnea,
Objective data shortness of breath, pursed-lip breathing, use of accessory muscles to breathe. The patient has a productive cough with thick, yellow sputum.
|
Ineffective airway clearance related to excessive secretions, as evidenced by
dyspnea, shortness of breath, pursed-lip breathing, Use accessory muscles for breathing, and the patient has a productive cough with thick yellow sputum. |
Goal
Patient to maintain an adequate airway clearance within 3 hours. Outcome criteria Patient to report no dyspnea, pursed-lip breathing, and use of intercostal muscles for breathing.
|
Auscultate breath sounds.
Demonstrate proper coughing techniques and encourage the patient to cough. Regulate fluid intake. |
Auscultation of breath sounds helps identify reduced or absent ventilation areas for appropriate management.
Proper coughing technique help in clearing secretions. Regulating fluid intake helps in optimizing fluid balance. |
Breath sounds auscultated, and findings documented.
The patient was taught to take deep breaths while coughing.
|
The patient maintains adequate airway clearance.
The patient reports no dyspnea or pursed-lip breathing; the patient is to use intercostal muscles for breathing. Goal fully met. Continue with the management. |
| Subjective data
The patient verbalizes discomfort.
Objective data The patient has a stage 2 pressure ulcer on the sacrum with an area of 2cm x 2cm. Surrounding skin is reddened and warm to the touch. |
Impaired Skin Integrity related to immobility secondary to obesity as evidenced by the patient having a stage 2 pressure ulcer on the sacrum with an area of 2cm x 2cm. Surrounding skin is reddened and warm to the touch. | Goal
To promote healing and prevent infection within 1 week. Outcome criteria Relieve discomfort for the patient. |
Apply a hydrocolloid dressing to the wound bed. Reposition the patient every 2 hours to relieve pressure. Increase protein intake in the patient’s diet. | Hydrocolloid dressing provides a moist environment that is conducive to healing.
Protein intake provides nutrients required for tissue repair. Repositioning promotes circulation. |
Dressing of the wound using hydrocolloid dressing was done.
The patient was repositioned every two hours. The patient was served a protein diet. |
The wound partially healed.
The patient reports reduced discomfort. No signs of infection. Goal partially met. Continue with the care as per the physician’s prescription. |
Reflection
As a nurse, I have found the ANA Data Set Elements helpful in my nursing practice. One specific example is the documentation of the patient’s pain severity using the LOINC code for pain severity assessment. Using a standardized language, other healthcare providers can easily understand the pain level the patient is experiencing and provide appropriate interventions (Themes, 2021). Another example is documenting the patient’s breathing status using the LOINC code for breathing status assessment. This helps identify any airway clearance issues and ensure appropriate interventions are implemented. Standardized language and data element sets also help to improve communication among healthcare providers, leading to better patient outcomes.
References
Alfaro, R. A., & Modi, P. V. (2020). Diclofenac. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557879/
Themes, U. F. O. (2021, July 29). Standardized nursing terminologies. Nurse Key. https://nursekey.com/standardized-nursing-terminologies/
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Activity 4
Professional Practice
Standardized nursing language is the method used for documentation. Using standardized language ensures commonly understood terms are used throughout the profession.
Develop a standardized care map for three NANDA nursing diagnosis of your choice using ANA recognized terminologies and data element sets.
Preform a Google search to pull up a detailed list of the ANA recognized Data Element Sets.
Data Element Sets:
PCDS NANDA
ICNP NIC
SNOMED CT NOC
LOINC® NMDS
CCC NMMDS
OMAHA ABCCodes
Additional Instructions:
1. All submissions should have a title page and reference page.
2. Utilize a minimum of two scholarly resources.
3. Adhere to grammar, spelling and punctuation criteria.
4. Adhere to APA compliance guidelines.
5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One: Instructions:
Paper • 2 page paper. Include title and reference pages.
| Professional Values – Professional Practice | ||||
| Description: The baccalaureate-graduate nurse will examine the importance of documenting nursing care in standardized terms while applying the ANA Recognized Terminologies and Data Element Sets to your area of nursing practice. | ||||
| Course Competencies: 1) Demonstrate understanding of the professional values which form the foundation of professional nursing. 5) Articulate the key elements of creating a safer health care environment. 7) Clarify personal and professional values and recognize their impact on decision-making and professional behavior. | ||||
| QSEN Competencies: 1) Patient-Centered Care, 3) Evidence-Based Practice, 4) Quality Improvement, 5) Safety | ||||
| BSN Essential VI | ||||
| Area | Gold Mastery | Silver Proficient | Bronze Acceptable | Acceptable Mastery not
Demonstrated |
| Standardized care map | Standardized care plan complete and easy to follow | Standardized care map complicated or difficult to follow | Care map not in standardized format | Does not submit a complete standardized care map in any format |
| ANA Data Element Sets | Fully identifies two Data Element Sets from the ANA that are important for the care map to provide high quality and safe patient care | Identifies one Data Element Sets from the ANA that are important for the care map to provide high quality and safe patient care | Identifies Data Element Sets that are not important for the care map | Does not identify Data Element Sets recognized by the ANA |
| NANDA Nursing Diagnosis | Identifies 3 NANDA Nursing Diagnosis | Identifies 2 NANDA
Nursing Diagnosis |
Identifies 1 NANDA
Nursing Diagnosis |
Does not identify a NANDA
Nursing Diagnosis |
| Nursing Intervention Classification System (NIC) | Includes 3 appropriate nursing interventions
from NIC |
Includes 2 appropriate nursing interventions
from NIC |
Includes 1 appropriate nursing intervention from
NIC |
Does not include appropriate interventions from NIC |
| Nursing Outcomes Classification System (NOC) | Includes 3 appropriate nursing outcomes from NOC | Includes 2 appropriate nursing outcomes from NOC | Includes 1 appropriate nursing outcomes from NOC | Does not include appropriate nursing outcomes from NOC |
| Reflection of nursing practice | Fully relates personal nursing practice to ANA Data Set Elements, identifying two specific examples
from personal practice |
Identifies personal nursing practice to ANA Data Set Elements, identifying one specific examples
from personal practice |
Identifies personal nursing practice to ANA Data Set elements but does not include specific examples from personal practice | Does not relate personal nursing practice to ANA Data Set Elements |
| APA, Grammar, Spelling, and Punctuation | No errors in APA, Spelling, and Punctuation. | One to three errors in APA, Spelling, and Punctuation. | Four to six errors in APA, Spelling, and Punctuation. | Seven or more errors in APA, Spelling, and Punctuation. |
| References | Provides two or more references. | Provides two references. | Provides one references. | Provides no references. |
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