Creating a concept map on a disease or chief complaint of assigned client. In this concept map Kaitlen is very detailed in explaining the health problem, risk and health promotion nursing diagnosis not only specific to the disease process, but more importantly specific to the client and their family. This is very important because as a nurse assessing priority guides the plan for individualized care.
For this specific client skin breakdown was a priority problem for them and their family due to the client’s immobility. Skin integrity is always a struggle when the client has limited mobility.
Kaitlen was able to use her critical thinking and clinical judgement skill to identify this client’s risk for inadequate tissue perfusion because of cerebral edema. She assessed the spouse’s readiness to learn and was able to outline teaching topics and techniques related to their concerns, which was the skin breakdown. The goals were SMART. Specific, measurable, attainable and had a time frame.