DIRECT- CUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET NURSING PROCESS TEMPLATE: Assessment (Recognizing Cues) Which client information is relevant? What client data is most important? Which client information is of immediate concern? Consider signs and symptoms, lab work, client statements, H & P, and others. Consider subjective and objective data. Analysis (Analyzing Cues) Which client conditions are consistent with the cues? Do the cues support a particular client condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Analysis (Prioritizing Hypotheses) What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care? In order of priority, identify the top 3 client conditions. Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning-specific, measurable, attainable, realistic/relevant, time-restricted- Goal setting) Implementation (Take actions) How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk) Evaluation (Evaluating Outcomes) What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the client's care outlook or status improve? Client Information (SBAR, H&P) An 85-year-old woman with hypertension and hyperlipidemia presented with gradual and progressive cognitive impairment for more than 2 years, involving cognitive domains of memory, executive function, visuospatial and mood. She has short-term memory loss such as forgetting whether she has eaten or showered. She will also ask the same questions repeatedly. However, her long-term memory remains intact. She has forgotten how to cook and has recently burnt the pot while cooking on the stove. She is also unable to manage finances and bradykinesia, absence of postural or rest tremors, normal limb power, tone and tendon reflexes. She has lower limb apraxia and mild postural instability. Her Mini-Mental State Examination (MMSE) was 16. While she scored 0 for delayed recall, she was able to recall all 3 objects with either category or lexical cueing. Main Concept (Should be focus of below map) Impaired memory CONCEPT MAP TEMPLATE: Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors Analyzing Cues/Conditions Generate Solutions/Outcomes/Interventions SMART Planning 1. 2. 3. 4. 5. Evaluating Outcomes 1. 2. 3. 4. 5. 1. 2. 3. 1. 2. 3. 4. 5. Prioritizing Hypotheses Taking Action-(How To)