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ASHLEY WOLANZYK
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 Reason for Needing Health Care
SEE OTHER ATTACHMENT PLEASE
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.
Don’t know where to put:
#1 Key Problem/ND # Key Problems/ND AST 1000
IMPAIRED GAS EXCHANGE ALT 365
Branden scale?
Supporting Data: Metabolic acidosis
-Pleural effusion
-ABG: pH 7.46, pCO2 31.5, pO2
148.5, HCO3 22.1
-Uncompensated respiratory
alkalosis
-Extensive infiltrate in right lung
-Pulmonary contusion due to CPR
-Vent A/C with FiO2 40, PEEP 8,
TV 450, rate 16
#2 Key Problem/ND:
#5 Key Problem/ND
IMPAIRED SPONTANEOUS
DECREASED CARDIAC
VENTILATION OUTPUT
-L radial pulse, bilat pedal and
Supporting Data: Reason For Needing Health Care PT pulses needed to use
-Acute respiratory failure (Medical Dx/ Surgery) Doppler to find
-On ventilator -syncope and collapse due to bilateral PE -Generalized edema, BUE and
-Mode A/C, TV 450, PEEP 8, -cardiac arrest 2x in ED with seizure-like BLE
rate 16, FiO2 40 activity -Hemorrhage d/t liver lac
-Diprivan (propofol) IV -liver lac with internal hemorrhage due to -Decreased RBC, HGB, HCT
CPR -levophed
-Mouth care q2h
-CTA chest showed straining of
-peridex -ex lap
R ventricle
-50 yo female, full code, allergy: penicillin -Wt gain 8 lbs since prior day
Kay assessments: VS with focus on -Anxiety
respiratory and cardiac -vasopressin
Step 3: Draw lines between related problems. Number boxes as you prioritize problems.
LASTLY- label the problem with a nursing diagnosis.
Predicted Behavioral Outcome Objective (s): The patient will maintain SpO2 >92% with normal heart
rate on the day of care.
Evaluation of outcome objectives: Goal met: the patient was 100% on ventilator (FiO2 40, TV 450, PEEP
8) and heart rate remained 86-98 bpm.
1. Assess ventilator settings 1. A/C, rate 16, FiO2 40, PEEP 8, TV450
2. Administer sedatives to facilitate comfort/rest 2. Diprivan (propofol) at 5.2 mL/hr
3. Suction as needed and hyperoxygenate 3. Tolerated suctioning, scant amount of
secretions noted
4. Analyze ABG’s 4. pH 7.46, pCO2 31.5, pO2 148.5, HCO3 22.1
5. Move ETT to other side of mouth 5. Increase pt comfort, prevent skin
breakdown
6. Mouth care q2h 6. Tolerated mouth care, peridex, no signs of
discomfort
7. Assess bilateral breath sounds q2h 7. Lungs CTA bilaterally
Evaluation of outcome objectives: Goal met: the patient tolerated ventilation and exhibited moist
mucous membranes.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
4
Predicted Behavioral Outcome Objective (s): The patient will exhibit no signs of acute pain via 0 out of 10
on CPOT pain scale on the day of care.
Evaluation of outcome objectives: Goal met: the patient remained free of pain as evidenced by 0 on
CPOT scale.
Predicted Behavioral Outcome Objective (s): The patient will have VS that reflect baseline, and gestures
/facial expressions reflecting decreased distress on the day of care.
1. Assess for physical reactions to anxiety 1. Pt did not exhibit any nonverbal
expressions indicating anxiety
2. Assure pt that feeling anxious is normal 2. Pt looked at me and moved hand
toward me.
3. Remove sources of anxiety 3. Medication to decrease pain, verbal
reassurance was acknowledged
with gesture “thumbs up”
4. Explain procedures beforehand 4. Pt nonverbal cue; she heard me
5. Use healing touch 5. Increased pt comfort level
6. Teach family signs of anxiety to report 6. Family verbalized understanding
Evaluation of outcome objectives: Goal met: the pt VS remained at baseline (aeb BP 118/61-135/65, HR
86-98 bpm, RR 16-18 per min) and she gestured with thumbs up and nods.
Predicted Behavioral Outcome Objective (s): The patient will maintain NSR and VS WNL on the day of
care.
Evaluation of outcome objectives: Goal met: the patient VS were WNL (BP 118/61-135/65, HR 86-98
bpm, RR 16-18 per min) and NSR.
Predicted Behavioral Outcome Objective (s): The patient will not exhibit signs of infection (elevated
temperature, elevated WBCs) on the day of care.
Evaluation of outcome objectives: Goal not met: pt had elevated temperature (99.6-100.8F) and elevated
WBCs of 14.6