Care Map

Include on the care map all parts of the nursing process using the template provided:

Please list all data cluster sets and which Gordon’s pattern are represented by each data cluster in the box on the template. Which Gordon’s patterns are Functional or Dysfunctional?

List the identified nursing diagnoses correctly written in priority order from highest to lowest priority.

NDx: Problem related to ________ Evidenced by ____________ (include all of the evidence from the cluster): this problem is the priority because…..next problem, etc.

3. Write a patient-centered goal statement to reduce or resolve the problem identified.

4. Write patient-centered expected outcomes in SMART format showing advancement toward the goal.

5. List all chosen nursing interventions and provide evidence based rationale for each intervention. Each interventions chosen needs to help this patient to meet his or her goal? (Look at each intervention and explain.) All nursing interventions and evid based rationales must have a citation.

6. What reassessment data would a nurse expect to assess if the client is meeting his or her goal? And Write at least one reassessment data that would indicate the client is not meeting the goal? Put this in the evaluation box on the template.

Please be sure to include all references on your reference page.

The care map is a written version of the nursing process and it is “used to organize patient data, analyze relationships in the data, establish priorities, build on previous knowledge, identify what you do not understand, and enable you to take a holistic view of the patient’s situation (Schuster, 2002).”

 -The nursing process involves critical thinking and is the foundation of what nurses do. The steps are:

 -Assessment- gathering clinical data from a variety of sources to support the decisions you make about the patient.

 -Diagnosing- identifying problems that represent the patient’s responses to the medical diagnosis, problem, or reason for seeking care.

 -Planning- developing a plan, with goals, to alleviate the problems.

 -Implementing- providing the care based on the plan you created.

 -Evaluating- reviewing the care you provided and determining whether the care provided has alleviated the patient’s problems and that the goals you set have been reached.