Key Problem (2 pts each) : 4 key problems are required per scenario. Each key problem must include the items below:
Nursing Diagnosis ND(5 pts each): -Must be an Approved NANDA Nursing Diagnosis
Related to (2pts each):
As Evidenced by (2 pts each):
Supporting Data(2 pts each):
Outcome(2 pts): 1 outcome required.
Intervention with Rationale(6pts): 3 interventions each with its rationale ( i.e. 1 intervention with 1 rationale)
Patient/Family Teaching or Discharge Planning/Referrals(4 pts): As related to the key problem
SAMPLE ONLY (I am using just two interventions, you will submit three)
Care Map Example. Using just two interventions and rationales
Patient X is a 47 year old male with a history of a fall 6 years ago in which he sustained nerve damage that causes him chronic lower back pain. Occasionally the pain radiates down his thigh and up to his shoulder. Additionally, he complains of poor pain management and that “the drugs don’t work.” The patient is noted to constantly rub his back and states that he cannot work due to the pain.
Key problem: chronic lower back pain
ND: Chronic Pain
Related to: nerve damage
As evidenced by: patient reporting lower back pain for six years
Supporting data: rubbing his back, statement that drugs do not work, patient cannot work due to pain
Outcome: Patient reports no pain or decreased level of pain.
Interventions: (again, in example I have only 2 interventions, assignment requires 3)
1) Patient will maintain a journal of what works for pain and what does not.
a. Rationale: systematic tracking helps to improve pain management
2) Explore different medications for pain.
a. Rationale: different medications or combinations may work for this patient
Patient teaching: educate on limiting activity that will cause excessive pain or reinjury and educate on proper medication use