Amanda Doran
CC Concept Map
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
Risk for impaired skin Fluid imbalance Ineffective airway
integrity clearance
Key Problem
Key Problem Reason for Needing Health Care Ineffective breathing
Impaired oral mucous ARDS pattern
membrane HIV
Hep C
PCP Pneumonia
Mechanical Ventilation
Key Problem Key Problem Key Problem
Decreased nutritional Impaired gas exchange Inability to communicate
intake
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Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab Data don’t
tests, medical history, emotional state and pain. Also, identify key assessments that are know where
related to the reason for health care (chief medical diagnosis/surgical procedure) and put to put in
these in the central box. If you do not know what box to put data in, then put it off to the boxes:
side of the map.
#7 Key Problem/ND #4 Key Problems/ND #2 Key Problem/ND
Risk for impaired skin integrity Fluid imbalance Ineffective airway clearance
Fentanyl @ 5mcg/hr Generalized edema 2+ Diminished breath sounds
NPO Creatinine 0.5 Brown thick secretions
Generalized edema BUN 35 Hx COPD
Impaired mobility Na 134 Hx smoker
Unresponsive to pain Foley Rhinovirus
Blister L axilla IJ TL D5NS @ 40mL/hr Pneumonia
Excoriated peri area and groin Pulmonary edema Solu-Medrol
Good skin turgor SIADH DuoNeb
BG: 228 Albumin: 2.3 Na: 134 Hgb: 6.3
Protein 4.9
Miconazole ointment
#5 Key Problem/ND:
#3 Key Problem/ND
Impaired oral mucosa membrane
Ineffective breathing pattern
NPO
AC/VC
Mechanical Ventilation
Reason For Needing Health Care TV 400
Thrush in oral cavity
Pulmonary edema FiO2 50%
Mycostatin 5mL
ARDS Rate 32
Chlorhexidine
HIV PEEP 20
Moist mucous membranes
Hep C SpO2 97
Protein: 4.9 Albumin: 2.3
PCP Pneumonia Fentanyl
ETT
Mechanical Ventilation ARDS, pneumonia
SIADH Rhinovirus
Rhinovirus Compensated Respiratory
acidosis
Allergy: PCN Pulmonary edema
#6 Key Problem/ND #1 Key Problem/ND #8 Key Problem/ND
Decreased nutritional intake Impaired gas exchange Inability to communicate
NPO Fentanyl Mechanically ventilated
High residual from OG SpO2 97% Sedated
Tube Feed discontinued COPD Fentanyl @ 5mcg/hr
Phosphorus 1.6 PCP Pneumonia Hx Bipolar depression
Albumin 2.3 ARDS Hx PTSD
Hyperactive bowel sounds Rhinovirus Unresponsive to pain
Senakot BID Pulmonary edema ETT
Compensated Respiratory
acidosis
DuoNeb
Solu-Medrol BID
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
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Step 3: Draw lines between related problems. Number boxes as you prioritize problems.
LASTLY- label the problem with a nursing diagnosis.
Step 4: Identification of goals, outcomes and interventions.
Step 5: Evaluation of Outcomes
Problem # __7_____: Risk for impaired skin integrity
General Goal: Intact skin
Predicted Behavioral Outcome Objective (s): The patient will……
Have no further skin breakdown
on the day of care.
Nursing Interventions Patient Responses
1. Assess skin hourly 1. Skin pink, moist. Blisters L axilla
2. Reposition Q2h 2. No new skin breakdown
3. Maintain dry linens 3. Skin dry and intact
4. Provide alternate pressure mattress 4. No new skin breakdown
5. Apply Mycostatin to skin folds 5. No new skin breakdown
6. Maintain good skin hygiene 6. Skin clean and dry
7. Protect bony prominences will 7. No new skin breakdown
pillows
8. Monitor for incontinence 8. Foley catheter in place. No BM
Evaluation of outcome objectives:
Patient goal met; no evidence of further skin breakdown on shift
Problem # ___4____: Fluid imbalance
General Goal: Maintain proper fluid balance
Predicted Behavioral Outcome Objective (s): The patient will……
Have decrease from prior days weight of 224 pounds
on the day of care.
Nursing Interventions Patient Responses
1. Administer IV fluids as ordered 1. D5NS continuous at 40mL/hr
2. Monitor I&O 2. Intake
3. Monitor lab values 3. Na 134, Hct 20.2, RBC 2.14
4. Monitor vital signs. 4. BP 107/63, HR 93-100
5. Apply cooling blanket 5. Temperature 99.8
6. Daily weights 6. 225 lb (224 lb 11/8)
7. Assess skin turgor and mucous membranes7. Turgor good, mucous membranes pink,
moist, and intact
8. Assess edema 8. Generalized edema throughout body
Evaluation of outcome objectives:
Pt goal not met; weight increased to 225 pounds on day of care
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
4
Step 5: Evaluation of Outcomes
Problem # ___2____: Ineffective airway clearance
General Goal: Maintain airway clearance
Predicted Behavioral Outcome Objective (s): The patient will……
Maintain SpO2 above 95% at all times
on the day of care.
Nursing Interventions Patient Responses
1. Provide oral care Q4h with 1. SpO2 97%
chlorhexidine & Mycostatin as 2. SpO2 97%
ordered 3. AC RR 32, FiO2 50%, vT 400,
2. Monitor SpO2 PEEP 20
3. Assess ventilator settings 4. Lung sounds diminished BL
4. Assess lung sounds lower lobes
5. Hyper-oxygenate and suction prn 5. Thick secretions
6. Administer Flonan, DuoNeb, Solu- 6. SpO2 97%
Medrol, Perforomist, Pulmicort as ordered 7. X-ray ARDS, pneumonia
7. Assess chest x ray 8. SpO2 97%
8. Maintain HOB 30 degrees
Evaluation of outcome objectives:
Pt goal met; SpO2 97%, lung sounds diminished but clear.
Problem # ___5____: Impaired oral mucosa membrane
General Goal: No lesions or thrush evident
Predicted Behavioral Outcome Objective (s): The patient will……
Maintain intact, moist oral membranes free of ulceration, inflammation, and infection
on the day of care.
Nursing Interventions Patient Responses
1. Assess mucous membranes 1. Mucous membranes pink, moist, intact
2. Provide oral care q4h 2. Mucous membranes pink, moist, intact
3. Apply Mycostatin as ordered 3. Oral mucosa free of thrush
4. Apply lip moisturizer q4h 4. Lips smooth, pink, intact
5. Apply chlorhexidine mouthwash 5. Mucous membranes pink, moist, intact
6. Monitor nutritional status 6. NPO
Evaluation of outcome objectives:
Pt goal met; oral mucosa pink, moist, and intact throughout shift
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
5
Step 5: Evaluation of Outcomes
Problem # ___3____: Ineffective breathing pattern
General Goal: Breathing without distress
Predicted Behavioral Outcome Objective (s): The patient will……
Maintain SpO2 above 94% with no signs of nasal flaring or use of accessory muscles
on the day of care.
Nursing Interventions Patient Responses
1. Monitor administration of 1. SpO2 97%
DuoNeb & Flonan 2. Mechanical ventilation; FiO2
2. Administer oxygen as ordered 50%
3. Monitor continuous pulse ox 3. SpO2 97%
4. Observe for cyanosis around 4. No cyanosis observed
mouth and mucous membranes 5. Breath sounds clear. Diminished
5. Assess breath sounds BL lower lobes
6. Monitor RR, depth, and ease 6. RR 32, no use of accessory muscles
7. Monitor ventilator settings 7. AC RR 32, FiO2 50%, vT 400,
8. Elevate HOB 30 degrees PEEP 20
8. SpO2 97%
Evaluation of outcome objectives:
Pt goal met; no use of accessory muscles or nasal flaring. SpO2 97%
Problem # ___6____: Decreased nutritional intake; less than body requirements
General Goal: increase albumin and protein
Predicted Behavioral Outcome Objective (s): The patient will……
Have increase from prior days albumin and protein
on the day of care.
Nursing Interventions Patient Responses
1. Assess lab values 1. Albumin 2.3 Protein 4.9
2. Daily weights 2. 11/8/18 224 lbs 11/9/18 225 lbs
3. Administer D5NS continuous at 40 mL/hr 3. BS Na
4. Assess residual 4. 50 mL residual
5. Restart TF 5. Held
6. Assess skin turgor 6. Skin turgor good
Evaluation of outcome objectives:
Pt goal not met; unable to restart TF, albumin decreased from 2.4 on 11/8 and protein decreased from 5.3 on
11/8
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
6
Step 5: Evaluation of Outcomes
Problem # ___1____: Impaired gas exchange
General Goal: improved ventilation
Predicted Behavioral Outcome Objective (s): The patient will……
Maintain SpO2 above 95%
on the day of care.
Nursing Interventions Patient Responses
1. Monitor RR, depth, and ease 1. RR 32, no use of accessory muscles
2. Assess ABG’s 2. pH 7.392 pCO2 47.1 HCO3 28.0
3. Monitor continuous pulse ox 3. SpO2 97%
4. Raise HOB 30 degrees 4. SpO2 97%
5. Monitor sedation via RASS 5. RASS -5
6. Turn q2h 6. Lung sounds diminished
7. Administer Fentanyl to decrease 7. Fentanyl d/c due to RASS
O2 demand 8. Thick secretions, maintained
8. Hyper-oxygenate and suction prn SpO2>95%
Evaluation of outcome objectives:
Pt goal met; SpO2 97%, ABG showing compensated respiratory acidosis on shift
Problem # ___8____: Inability to communicate
General Goal: use effective non-verbal communication
Predicted Behavioral Outcome Objective (s): The patient will……
Nod yes or no and follow commands
on the day of care.
Nursing Interventions Patient Responses
1. TV off and group care 1. No response to pain; RASS -5
2. Encourage non-verbal communication 2. Pt doesn’t follow commands
3. Explain all procedures 3. No response to pain
4. Assess pain using CPOT 4. CPOT 0
5. Monitor RASS 5. RASS -5
6. Assess non-verbal communication. 6. Patient doesn’t respond to pain or follow commands
Evaluation of outcome objectives:
Pt goal not met; pt does not follow commands or nod appropriately. Fentanyl d/c; no change.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
