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The purpose of a concept map is to visualize connections between ideas, connect new ideas to previous ideas, and to organize ideas logically. Concept maps can be an extremely useful tool to help organize and plan care decisions. By utilizing a concept map, a nurse can simplify the connection between disease pathways and emotional, cultural, socioeconomic, and personality considerations that impact a patient’s health.


Develop a patient-centered concept map for a chosen condition. This could be a disease, or a disorder based upon the best available evidence that has been individualized to treat your patient’s health, economic, and cultural needs. Write a brief 3–5 page narrative that explains why the resources cited in the concept map and narrative are valuable and relevant. Describe how you incorporated the patient’s individual culture, identity, abilities, and beliefs into the plan of care. Also, be clear about your specific communication strategies for relating information to the patient and their family.

The bullet points below correspond to grading criteria in the scoring guide. Be sure that your map and narrative address all of the bullets below, at minimum.

Part 1: Concept Map

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· Design a patient-centered concept map based upon the best available evidence for treating a patient’s specific health, economic, and cultural needs.

. Include objective and subjective assessment findings to support three nursing diagnoses.

. Include interventions that will meet your patient’s individual needs.

. Include measurable outcomes for each nursing diagnosis using SMART goals: (S)pecific, (M)easurable, (A)chievable, (R)elevant, and (T)ime-bound.

Part 2: Supporting the Concept Map

· Analyze the needs of a patient, and those of their family, to ensure that the interventions in the concept map will be relevant and appropriate for their beliefs, values, and lifestyle.

. Explain how you incorporated the patient’s individual culture, identity, abilities, and beliefs into the plan of care.

. Consider how your patient’s economic situation and relevant environmental factors may have contributed to your patient’s current condition or could affect future health.

. Consider how your patient’s culture or family should inform your concept map.

· Apply strategies for communicating with the patient and their family in an ethical, culturally sensitive, and inclusive way.

. Explain how you will communicate the proposed interventions and evaluation plan in an ethical, culturally sensitive, and inclusive way. Ensure that your strategies:

. Promote honest communications.

. Facilitate s


Support for Patient Centered Concept Map

Learner Name

Capella University

NURS-FPX6011 Evidence-Based Practice for Patient-Centered Care and Population Health

Instructor Name


Concept maps are a tool that can be used to develop an individualized plan of care. Evidence-based practice should support the planned interventions to meet the patient’s needs. The attached concept map was developed to plan care for a diabetic patient who has been non-compliant with her self-care regimen.

Patient Needs Analysis

The most important nursing diagnosis for this patient is Risk for unstable blood glucose level
(Ladwig et al., 2019). The patient has reported several factors that put her at risk for this diagnosis. She has had episodes of hypoglycemia where her family has called 911 and has continued to have difficulty with blood glucose monitoring and reports not eating well. She is reporting declining interest in overall diabetes management over the past few years. The second most important nursing diagnosis is Ineffective health management
(Ladwig et al., 2019). The patient has reported feeling an overall loss of interest and hopelessness in meeting glycemic goals over the past few years. Additionally, she has reported feeling overwhelmed with taking care of her grandchildren which has been intermittent and unexpected due to school closures related to COVID 19. The third diagnosis that is appropriate for Ana is Readiness for enhanced health management
(Ladwig et al., 2019). Ana is seeking care and help now because she recognized her choices are not healthy for her and she is concerned as well as her family.

According to the American Diabetes Association Professional Practice Committee (ADAPPC) standards of care “Significant changes in life circumstances, often called social determinants of health, are known to considerably affect a person’s ability to self-manage their condition” (ADAPPC, 2022b). COVID has had a significant impact on individuals, families, and communities. This patient and her family have been impacted and it is contributing to the patient’s ability to effectively manage her diabetic diagnosis. According to the ADAPPC, “There are four critical times to evaluate the need for diabetes self-management education to promote skills acquisition in support of regimen implementation, medical nutrition therapy, and well-being: at diagnosis, annually and/or when not meeting treatment targets, when complicating factors develop (medical, physical, psychosocial), and when transitions in life and care occur” (2022b). This patient and family are experiencing at least two out of four of these critical times. The intervention to refer for Depression screening and Diabetes Self-

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Patient Scenario:

Ana is a 67-year-old Hispanic female. Ana was diagnosed with diabetes 10 years ago. Ana reports that when she first received this diagnosis she checked her blood sugar all the time, that she “ate all sugar free food,” that she walked daily, and that she never missed a dose of her medicine. In the past few years Ana reports that she has “gotten so tired of it all,” and says “there is nothing I can do, everyone in my family has diabetes there’s no stopping it.” Due to increasing A1C, Ana was recently started on insulin and reports she really didn’t want to but “the doctor told me I had to, my blood sugars were too high.” Ana reports she is trying to check her blood sugars and take all her medicine, but has felt very busy sometimes watching several of her grandkids unexpectedly due to school closures due to COVID quarantines. Ana reports the family is not comfortable seeking childcare and prefers to “keep the kids safe with me.” She also states “I just get so busy I don’t have time to check my blood sugar. I get so overwhelmed some days I don’t even feel hungry, some days I don’t eat much.”

Per review of her medical record, Ana has not attended the last two Primary Care appointments, is not returning calls, and has not been reporting blood glucose readings. Ana reports last week “I had to go to the hospital, the doctor needs to change my insulin, it’s not right.” Ana reports her husband called 911 last week because “I couldn’t answer him, he got scared and called 911.” Hospital records indicate Ana was found by EMS with confusion and low blood sugar. She was treated for hypoglycemia by EMS and taken to the hospital. She was released the same day with instructions to see her primary care doctor. The records also indicate Ana had arrived by EMS two months ago for a similar episode. Ana states “I don’t have time for all this medicine, but my family is worried about me.” Ana reports after the last 911 call and ER visit that her she, husband, and 3 kids got very scared, stating “I know I need to be more careful and do better, I know that now.” Ana is here with her husband and one of their daughters.

Nursing Diagnosis 2

Ineffective health management (Ladwig et al., 2019).

Nursing Diagnosis 3

Readiness for enhanced health management (Ladwig et al., 2019).

Assessment Findings:

Patient seeking help to better manage blood glucose levels

Family supportive and concerned about patient

Assessment Findings:

Sometimes does not check blood glucose before insulin dosing

Inconsistently taking oral diabetic medication

Feeling of h