Clinical Data Management Essay Example Paper
Introduction
A nursing diagnosis is a clinical judgment by a person, community, family, or group regarding a human reaction to health conditions, life processes, or susceptibility to that reaction. A nursing diagnosis forms the foundation for selecting nursing practice to accomplish results for which the physician is accountable (Ellis, 2020). It is also used to communicate the healthcare needs of the people and integrate the healthcare providers within the healthcare provision system. Thus, the North American Nursing Diagnosis Association has focused on the establishment and execution of standardized languages for nursing diagnoses in nursing care plans. Standardized care plans play an essential role in enhancing clinical data management’s effectiveness and usability (Doenges, Moorhouse & Murr, 2016). Standardization enhances the clinical quality and significantly improves effective communication and involvement of patients in care planning. This paper seeks to develop a standardized care map for acute pain and post-trauma syndrome based on the NANDA nursing diagnosis.
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Acute Pain Care Map
| Nursing Diagnosis | Subjective/Objective Data | Nursing Outcomes | Interventions |
| Acute pain:
knee injury Evidence: the patient reports consistent pain in the left knee which has lasted for over six months, despair, exhaustion and rubbing of the painful knee. |
Subjective
§ The patient complains of pain in the left knee that has lasted almost six months. § The agony has become a burden to her and has affected her movements. § The pain has left her in exhaustion and depressed. § Objective § Patients come in with grumbling of knee pain. § The patient looks worn-out with dark circles beneath her eyes. § She always rubbing her knee. |
§ The patient is required to inform the medical attendant about improvement of knee pain and the progression by the following follow-up arrangement of having an alternative of dealing with daily activities.
§ The patient will reconsider the non-invasive remedy from the measures of discomfort to facilitate her coping with the agony. § Patient should clearly communicate how to take the approved medication for the pain. |
§ The healthcare assistant will make an assessment of the patient’s progress report, and increase the daily exercises at the next appointment.
§ The healthcare professional must provide an analysis of the progress of the pain treatment and the desired outcome of the treatment for the individual. § The nurse shall teach the patient non-invasive relief from pain measures to allow the patient to come to terms with the agony. § The nurse must educate the client on how to take the prescription medications with precision for knee pain. |
Post Trauma Syndrome
| Care map | Intervention | Implementation | Evaluation |
| Nursing diagnosis: Post Trauma Syndrome
Related to: distressing occurrences, even when one is away from the usual human experience. Evidence: nightmares which result in psychological numbness, intrusive cognition, loss of memory and hallucinations. Short term goal: patient can show adequate capability of managing emotional reactions.
Long-term goal: patient will overcome the experience of trauma, rebuild the crucial connections and set long term goals. |
§ Use friendly approach which is nonthreatening. This is designed to create trust.
ORDER YOUR PAPER HERE§ Stay with patient through hallucinations and nightmares. This provides reassurance of security and wellbeing. § Allow the patient to talk about the injury at their own time. § Help patient to fully comprehend the injury if conceivably possible. § Share the views of weakness with the patient. |
The purpose of nursing treatment of patients with trauma-related issues is to:
§ Ensure security assurance § Lower the maladaptive symptom levels. § Showcase coping strategies. § Ensure flexible development during the process of grieving. |
Assessing care for post trauma syndrome patients is primarily focused on:
§ Can the patient share information about the trauma incident without undergoing any feelings of anxiety and depression? § Efficiently and effectively achieving outcome criteria established previously. |
Conclusion
As a nurse, the care maps above tend to attribute a great deal to my nursing practice in various ways. Take for example the case of a patient with acute pain. As a healthcare provider, relieving the pain from the patient is my important obligation and one must have adequate evidence in doing so. Thus, adequate evidence is available on the above care plan to enable a healthcare provider to select the right modality for pain relief. Furthermore, it serves as a guide on what direction to take to focus on improving pain management when it comes to the post-trauma syndrome care plan, as shown above. Therefore, a care map plays a crucial in basing care on evidence.
Overall, the above care map helps to teach documentation. The care map has clearly given an outline of the observations to make, the actions to take in nursing, and the directions required by the patients. The intention of creating a care plan is that it helps nurses to pull information from several different fields of science as they discover to use critical thinking and the nursing processes to solve problems. As nurses create more care plans, their skills for information processing and thinking like professional healthcare providers become more firmly embedded in their practices.
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: Planning, individualizing, and documenting client care. FA Davis.
Ellis, P. (2020). Nursing diagnosis. Patient Assessment and Care Planning in Nursing, 75.
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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 two NANDA nursing diagnosis of your choice using ANA recognized terminologies and data element sets. Resources: 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: All submissions should have a title page and reference page. Utilize a minimum of two scholarly resources. Adhere to grammar, spelling and punctuation criteria. Adhere to APA compliance guidelines. Adhere to the chosen Submission Option for Delivery of Activity guidelines. Submission Options: Choose One: Instructions: Paper 2 to 3-page paper. Include title and reference pages Clinical Data Management Essay Example Paper