Anthony Coonfare 1

Step 1. Write the key problems the patient has based on the data collected. The key
problems are also known as the concepts. Start by centering the reason for seeking health
care (often a medical diagnosis). Next, list the major problems you have identified based
on the assessment data collected on the patient.

SLOPPY COPY
Key Problem: Key Problem: Key Problem
Deficient Fluid Volume Decreased Cardiac Output Impaired Gas Exchange

Supporting data: Supporting data: Supporting data:

Tachycardia Hypotension (without intervention) Respiratory failure
Hypotension (without Edema (+2 pitting BUE and BLE) Partially compensated
intervention) Decreased peripheral pulses (+1 in all respiratory acidosis
Hemorrhage extremities) Vent settings:
-2073 cumulative fluid Hemorrhage AC/VC, FIO2 .50, Rate 12,
balance prior day Hx of hypertension TV 600, PEEP 20.
Dry mucous membranes Acute kidney injury Tachycardia
Vasopressor- IV Levophed

Key Problem: Reason for Needing Health Care: Key Problem:

Impaired Skin Integrity Complications following gastric bypass Ineffective Peripheral
surgery. Found to have a gastric artery Tissue Perfusion
Supporting data: bleed leading to hemorrhagic shock,
Upper lip wound hypoxia and hypercapnia, acute anoxic Supporting data:
Immobility (sedated) encephalopathy, acute kidney injury, and Hypotension
ETT liver shock Tachycardia
Obesity 53 yo Male Full code Elevated BUN 39 and
Dry mucous membranes Creatinine 2.9
Key assessments: Weak peripheral pulses (+1
VS with focus on cardiac and respiratory in all extremities)
Cool extremities
Allergies: Foods
Key Problem:
Electrolyte imbalance
Key Problem
Supporting data: Key Problem:
Dry mucous membranes Impaired Social Interaction
Hypotension (without
intervention) Supporting data:
Abnormal serum Inability to communicate
electrolytes: decreased Na+ (sedated/ETT)
127, Cl- 89, increased K+ Immobility
5.8, PO4 4.9 Unfamiliar environment
History of PTSD, major
depressive disorder

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

 Anthony Coonfare 2

Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab
tests, medical history, emotional state and pain. Also, identify key assessments that are
related to the reason for health care (chief medical diagnosis/surgical procedure) and put
these in the central box. If you do not know what box to put data in, then put it off to the
side of the map.

#3 Key Problem: #2 Key Problem: #1 Key Problem

Deficient Fluid Volume Decreased Cardiac Output Impaired Gas Exchange

Supporting data: Supporting data: Supporting data:

Tachycardia Hypotension (without Respiratory failure
Hypotension (without intervention) Partially compensated
intervention) Edema (+2 pitting BUE and respiratory acidosis
Hemorrhage BLE) Vent settings:
-2073 cumulative fluid balance Decreased peripheral pulses (+1 AC/VC, FIO2 .50, Rate 12,
prior day in all extremities) TV 600, PEEP 20.
Dry mucous membranes Hemorrhage Tachycardia
Hx of hypertension
Acute kidney injury
Vasopressor- IV Levophed

#6 Key Problem:
#4 Key Problem:
Impaired Skin Integrity
Ineffective Peripheral Tissue
Reason for Needing Health Care: Perfusion
Supporting data:
Complications following gastric bypass
Upper lip wound
surgery. Found to have a gastric artery bleed Supporting data:
Immobility (sedated)
leading to hemorrhagic shock, hypoxia and Hypotension
ETT
hypercapnia, acute anoxic encephalopathy, Tachycardia
Obesity
acute kidney injury, and liver shock Elevated BUN 39 and
Dry mucous membranes
53 yo Male Full code Creatinine 2.9
Weak peripheral pulses (+1 in
Key assessments: all extremities)
VS with focus on cardiac and respiratory Cool extremities

Allergies: Foods

#5 Key Problem: #7 Key Problem:

Electrolyte imbalance Impaired Social Interaction

Supporting data: Supporting data:

Dry mucous membranes Inability to communicate
Hypotension (without (sedated/ETT)
intervention) Immobility
Abnormal serum electrolytes: Unfamiliar environment
decreased Na+ 127, Cl- 89, History of PTSD, major
increased K+ 5.8, PO4 4.9 depressive disorder

Step 5: Evaluation of Outcomes

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Anthony Coonfare 3

Problem # ___1____: Impaired Gas Exchange

General Goal: Increased Gas Exchange

Predicted Behavioral Outcome Objective (s): The patient will show adequate signs of gas exchange AEB
SPO2 of greater than 95% on the day of care.

Nursing Interventions Patient Responses

1. Assess breath sounds q2hrs. 1. Rhonchi in bilateral upper lobes,

cleared with suctioning.
2. Assess ABG’s qshift. 2. Pts. ABG’s showed partially
compensated resp. acidosis.
3. Assess SPO2 qhr. 3. SPO2 remained greater that 96
(100-100)qhr.
4. PRN suctioning 4. Pt. suctioned as needed to
eliminate excretions.
5. Position patient in Semi-fowler 5. Pt. remained in Semi-fowler
position position during shift.
6. Administer adequate fluids to 6. Breath sounds cleared with
loosen secretions. suctioning.

Evaluation of outcome objectives: Outcome met during shift, Pt. SPO2 remained greater than 95% on the day
of care.

Problem # ___2____: Decreased Cardiac Output

General Goal: Adequate Cardiac Output needed for organ function
Predicted Behavioral Outcome Objective (s): The patient will demonstrate adequate cardiac output as
evidenced by MAP greater than 65 on the day of care.

Nursing Interventions Patient Responses

1. Monitor BP qhr. 1. MAP greater than 65 qhr.(71-74)

2. Monitor pulse oximeter qhr. 2. Greater than 96% qhr. (100-100)
3. Monitor cardiac rhythm qhr. 3. Cardiac rhythm sinus tachycardia qhr.
4. Monitor fluid intake and output qhr. 4. Output (1169) input (668), output
greater than input.
5. Apply ISCP sleeves as ordered. 5. ISCP sleeves remained on pt. during
shift.
6. Position patient in Semi-fowler position. 6. Pt remained in Semi-fowler
position during shift.
7. Assess for JVD during assessments q2hrs.7. No sign of JVD during assessments.

StepEvaluation of outcome
5: Evaluation objectives: Outcome met during shift, Pts. MAP remained greater than 65 throughout
of Outcomes
the day of care.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Anthony Coonfare 4

Problem # ___3___: Deficient Fluid Volume

General Goal: Fluid volume will return to normal level

Predicted Behavioral Outcome Objective (s): The patient will maintain normal blood pressure (120/80), pulse
(60-100), and body temp (97-99) during on the day of care.

Nursing Interventions Patient Responses

1. Monitor vital signs qhr. 1. Pulse elevated (101-102), Bp

2. Assess skin turgor over bony hypotensive (102/53-111/58)
prominences with head to toe temp elevated (99.7-99.9) during
assessment q2hr. day.
3. Observe for dry tongue/mucous 2. Skin turgor WDL during shift.
membranes q2hr. 3. Tongue/mucous membranes dry.
4. Monitor total fluid intake and 4. Overall fluid balance of -501ml
output qhr. during shift.
5. Note color of urine in relation to 5. No urine output during shift.
hydration status qhr. 6. Pulses +1 in all extremities.
6. Assess peripheral pulse strength.

Evaluation of outcome objectives: Outcome not met during shift, Pts. Body temp remained elevated above
defined limits. BP remained low throughout shift with a consistently low diastolic pressure, and HR remained
elevated during day of care.

Problem # ___4___: Ineffective Peripheral Tissue Perfusion

General Goal: Adequate peripheral tissue perfusion
Predicted Behavioral Outcome Objective (s): The patient will demonstrate adequate tissue perfusion as
evidenced by palpable peripheral pulses and warm and dry skin on the day of care.

Nursing Interventions Patient Responses

1. Check peripheral pulses with assessment 1. Peripheral pulses +1 in all extremities.

q2hrs.
2. Note skin color and temp. q2hrs. 2. Skin color remained appropriate for
ethnicity temp. cool in all
extremities
.
3. Check capillary refill q2hrs. 3. Capillary refill less than 3 sec in all
extremities
4. Note presence of edema in extremities 4. +2 pitting edema in all extremities.
during assessment q2hrs.
5. Note skin texture of heals with 5. Heals firm on assessment.
assessment q2hrs.
6. elevate edematous extremities. 6. Edema unchanged during shift.

Evaluation of outcome objectives: Outcome partially met, Pt. displayed weak peripheral pulses of +1, skin
remained cool, and dry on day of care.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
Anthony Coonfare 5

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Anthony Coonfare 6

Step 5: Evaluation of Outcomes

Problem # ___5___: Electrolyte imbalance
General Goal: Electrolytes will return to normal ranges

Predicted Behavioral Outcome Objective (s): The patient will maintain serum sodium between 132-146 on the
day of care.

Nursing Interventions Patient Responses

1. Monitor intake and output qhr. 1. Output (1169) input (668), output
greater than input.
2. Monitor daily weights 2. Pts weight decreased 16lbs from
previous day.
3. Review laboratory data qshift. 3. Serum NA+ 127
4. Administer parenteral fluids as 4. Pt. displayed adequate fluid
ordered. volume for true concentration of
electrolytes
5. Assess cardiac status with 5. Pt. remained tachycardic (101-
assessments. 102)throughout day, SI and S2
6. Assess neurological alterations heard.
with assessments. 6. Extension with painful stimuli,
pupils equal and reactive.

Evaluation of outcome objectives: Outcome not met during shift, Serum sodium remained lower than 132-146
during day of care serum sodium 127.

Problem # ___6___: Impaired Skin Integrity

General Goal: Regain integrity of skin surface
Predicted Behavioral Outcome Objective (s): The patient will demonstrate no further skin breakdown with no
further areas of redness and no increase in extent of further tissue involvement.

Nursing Interventions Patient Responses

1. Assess sight of skin impairment. 1. Upper lip wound, reddened and

weeping, remained same size.

2. Inspect and monitor site of skin 2. No changes during shift.

impairment for changes in character
of the wound during shift.
3. Maintain a moist wound-healing 3. Lip remained moist throughout shift.
environment.
4. Assess pts. nutritional status 4. Pt. not receiving nutrition, NPO.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Anthony Coonfare 7

5. Identify phase of wound healing. 5. Pt. shows characteristics of first phase

of wound healing as the wound was still
bleeding and weeping.
6. Protect area of further damage with 6. Barrier balm applied and maintained.
Barrier balm.

Evaluation of outcome objectives: Outcome met during shit, Pt. showed no further skin deterioration aeb no
further areas of redness and no increase in extent of further tissue involvement on day of care.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Anthony Coonfare 8

Step 5: Evaluation of Outcomes

Problem # ___7___: Impaired Social Interaction
General Goal: Regain social interaction

Predicted Behavioral Outcome Objective (s): The patient will use available opportunities to practice
interaction aeb maintaining eye contact when un-sedated or aroused on the day of care.

on the day of care.

Nursing Interventions Patient Responses

1. Spend time with patient. 1. Pt. non-responsive to visitors.

2. Provide music to stimulate client. 2. Pt. non-responsive to music.
3. Talk to patient even without 3. Pt. non-responsive to verbal
response. interaction.
4. Inform sedated pts of activities 4. Pt. showed no response to verbal
before performing. interaction.
5. Give visual stimuli to the pt. 5. Pt. non-responsive to visual
6. Allow family members to visit to stimuli.
interact with pt. 6. Pt. non-responsive to presence of
family members interaction.

Evaluation of outcome objectives: Outcome not met, Pt. was unable to maintain eye contact when un-sedated
or with interaction. Pt. remained unresponsive on day of care.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.