1

Step 1 . 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
boxes:
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.

#1 Key Problem/ND #8 Key Problems/ND #5 Key Problem/ND

Anoxic Impaired skin integrity Ineffective Kidney Function
Supporting Data:
On ventilator (A/C Mode) Supporting data: Supporting data:
Not breathing above the ventilator Stage 2 skin wound on coccyx Needs to be on peritoneal
MRI shows anoxic brain injury from inability to move dialysis.
EEG shows negative seizures Redness on coccyx area BUN- 71H
Patient went into cardiac arrest Apply topical hydrocortisone Creatine- 9.8H
over 6 minutes after foot cream Patient is anuric
amputation. (Hemorrhagic shock) Necrotizing fasciitis Weak muscles for urination
ABGS: pH- 7.44, PCO2- 33.8L, Wet gangrene in lower
PO2- 156.6H, HCO3- 22.7 extremities
Compensated Respiratory
Acidosis due to peritoneal dialysis
RR-12, SPO2-98%
#2 Key Problem/ND:
#6 Key Problem/ND
Ineffective Airway clearance
Inability for patient
/Risk for Infection
communication
Supporting Data: Reason For Needing Health Care
(Medical Dx/ Surgery) Supporting data:
Diminished Breath sounds rt
Abnormally high WBC count from Patient only responds to pain
white scanty secretions
necrotizing fasciitis, wet gangrene right foot, ETT tube in place
ETT suctioning every 2 hours
cardiac arrest and hemorrhagic shock due to Cuff Pressure secured
Turn every 2 hours
DKA and type 2 diabetes with peritoneal Does not open eyes to
WBC 15.8H
dialysis commands.
Wet gangrene infection low
Allergies: Benadryl, Clonidine Pupils are not reactive to light.
extremity
33 y.o male, Full Code In a Worry/Depressive state
Swollen tongue
Chronic type 2 diabetes Key Assessment:
Right lower lobe atelectasis VS with focus on Respiratory, blood
RR-12, SPO2-98% circulation, cardiac.

#3 Key Problem/ND #4 Key Problem/ND #7 Key Problem/ND

Inability to breath on own Brain Injury/no brain function Poor blood circulation to
lower extremities
Supporting data: Supporting Data:
On Ventilator Apnea test showed no brain Supporting data
Diagnosed as Anoxic function Necrotizing fasciitis in lower
Ventilator Mode A/C EEG test was done and was extremities.
Rate 12 negative for seizures Below the knee amputation in
FIO2 40% Patient is unresponsive with both lower extremities.
TV 450 passive ROM (spontaneous) Hemorrhagic shock after right
PEEP 5 movements foot amputation surgery
ET Tube in place Patient’s pupils are non-reactive resulting in cardiac arrest.
Patient does not breath above the to light or objects Peripheral pules 2+ bilateral
vent Step 3: Draw lines between related problems. Number boxes as you prioritize problems.
RR-12, SPO2-98%

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

 2

LASTLY- label the problem with a nursing diagnosis.

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # ___1____: Anoxic
General Goal: Restore oxygen to prevent damage and restore function

Predicted Behavioral Outcome Objective (s): The patient will…… tolerate decreased ventilator settings by
decreasing FIO2 and breathing above the ventilator rate of 12 with a spo2 higher than 90% on the day of care.

Nursing Interventions Patient Responses

1. Listen to beath sounds 1. Diminished breath sounds

2. Look at chest x-ray results 2. Lower right lobe atelectasis
3. Draw ABG Labs 3. Has compensated respiratory
4. Elevate Head of Bed 30 degrees acidosis
5. Suctioning and oral care Q2H 4. Less drainage in airway
6. Monitor SPO2 status hourly 5. White scanty sputum upon
7. Monitor Vitals hourly suction
6. SPO2 98%
7. HR- 91, BP- 149/110, RR- 12

Evaluation of outcome objectives: The patient did not improve in any way towards getting off of the ventilator
or being weaned off. This outcome was partially met because the SPO2 was at 98% but the patient did not
breath above the vent and stayed at a 12 RR.

Problem # ___2____: Ineffective airway clearance/Risk for infection

General Goal: No progressing signs of infection and better airway clearance
Predicted Behavioral Outcome Objective (s): The patient will…… have little to no secretions upon suction,
are clearer sounds, and stronger breath sounds.

on the day of care.

Nursing Interventions Patient Responses

1. Assess breath sounds 1. Diminished breath sounds

2. Administer Robinul 2. Secretions diminished
3. Increase FIO2 when suctioning 3. SPO2 98 % with scanty white sputum
4. Turn q2h 4. SPO2 didn’t drop upon turn
5. Encourage coughing 5. Patient couldn’t cough on own
6. Assess for GAG reflex 6. No GAG reflex upon suction
7. Oral care/suction Q4H 7. Mouth cleaned and suction q4h
Evaluation of outcome objectives: Patient was able to have less secretions/saliva r/t drug administration but
showed no signs of improving strengths of breaths or breathing on their own. The breath sounds/strength was
still diminished and labored at the end of the shift so this was not met.

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

 3

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # ___3____: Inability to breath on own
General Goal: Patient will improve on lung expansion and initialing own breaths

Predicted Behavioral Outcome Objective (s): The patient will…… be able to breath above the ventilator rate
of 12 with no accessory muscle use and signs of increased breath sounds from diminished on ay of care.

Nursing Interventions Patient Responses

1. Assess ETT 1. ETT is 8/24 @ lip

2. Assess airway and breathing 2. Clear diminished breath sounds
3. Monitor Ventilator Setting 3. No attempt to wean and SPO2
4. Suction Patient q2h 98%, 40 FIO2
5. Prevent complication of 4. Secretions were suctions q2h
ventilator pneumonia 5. No fluid in the lungs upon x-ray
6. Provide emotional support 6. Patient and family appreciated
7. Elevate HOB 30 degrees emotional support
7. Airway is more patent at 30
degrees

Evaluation of outcome objectives: Patients breath sounds did not improve, and we were not able to lower the
ventilator settings. The patient’s family appreciated the support and comfort through the day of care. The
PEEP stayed at 5 and the respiratory rate was never greater than 12 breaths per minute.

Problem # ___4____: Brain Injury/No Brain Function

General Goal: Improve neuro status
Predicted Behavioral Outcome Objective (s): The patient will…… be able to respond to commands and be
arousable upon command with pupillary reaction improving from sluggish to brisk on day of care.

Nursing Interventions Patient Responses

1. Look at EEG results 1. Negative for seizures

2. Pupil Reaction Test. 2. PERRL with sluggish reaction
3. Assist in R.O.M exercises 3. Complete Dependent muscle use
4. Assess patients alert and orientation 4. Patient was non-responsive to voice
5. Give Apresoline to control BP 5. Patients blood pressure is 149/110
6. Provide sensory stimulation of music 6. Patient did not react to stimulation
7. Sternal rub of relaxing music
7. Patient had facial grimace to rub
Evaluation of outcome objectives: Patients brain activity showed no signs of improvement and goals were
not met. Patient’s blood pressure is being stabilized with alternative medications and patient’s pupils are
sluggish to light and did not respond to commands.

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

 4

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # ___5____: Ineffective kidney function
General Goal: Improve kidney health and function

Predicted Behavioral Outcome Objective (s): The patient will…… show improved lab value results from prior
day of BUN at 73 and Creatinine at 12 on day of shift.

on the day of care.

Nursing Interventions Patient Responses

1. Monitor kidney lab values 1. BUN- 71H, Creatinine- 9.8H

2. Limit sodium and protein intake 2. NPO diet w/ peritoneal dialysis
3. Give anti-hypertensive drug 3. BP at 144/110 after Apresoline
4. Monitor signs of infection 4. Wet gangrene, WBC- 15.8H
5. Manage blood sugar 5. Blood sugar at 180 H
6. Monitor intake and output 6. No output, peritoneal dialysis-
7. Peritoneal Dialysis filtration 1,013, no input NPO.
7. peritoneal dialysis- 1,013

Evaluation of outcome objectives: The BUN was at 71 and the creatinine was at 9.8 which both slightly
improved from the day before. Patient was anuric and had no input or output on day of shift. I would say that
is partially met because they are still high but both improved.

Problem # ___6____: inability for patient communication

General Goal: Effective communication
Predicted Behavioral Outcome Objective (s): The patient will…… the patient will be able to respond to verbal
commands by shaking his head or blinking or any non-verbal communication tactic on day of care.

Nursing Interventions Patient Responses

1. Monitor signs for discomfort 1. Patient didn’t show any facial grimace
Like facial grimace or changing position.
2. Neurological assessment 2. Pain response to sternal rub,
Sluggish pupils, no hand grasp bilateral
3. Make sure ETT cuff is stabilized 3. Cuff stabilized, no secretions past
4. Reassurance and emotional support 4. Patient had no response
5. Assess if pt can follow verbal commands 5. Patient couldn’t follow commands
No response
6. Find new ways to communicate by 6. No new ways to communicate, no
Coded eye blinking or yes or no questions. response
Evaluation of outcome objectives: Patient was not able to find new ways of communication. Patient remained
non-verbal and did not respond to any verbal communication. Not met.
Step 4: Identification of goals, outcomes, and interventions.

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

 5

Step 5: Evaluation of Outcomes

Problem # ___7____: poor blood circulation to lower extremities
General Goal: Improve blood circulation and blood pressure

Predicted Behavioral Outcome Objective (s): The patient will…… have +2 palpable pulses bilaterally on all
4 extremities and will keep the systolic blood pressure below 160on the day of care.

Nursing Interventions Patient Responses

1. Elevate legs with a pillow 1. No swelling in the legs

2. Assess patients pain levels 2. Patient showed facial grimacing
(sternal rub) 3. HR- 91, RR-12, MAP-123,
3. Monitor vitals SPO2- 100%
4. Give BP medication 4. Patients’ blood pressure was at
5. Do leg exercises R.O.M 144 systolic after Apresoline
movements
6. Infection prevention on open 5. Patient was dependent on all
wound of amputation by exercises
assessing dressing for drainage or 6. Dressing had no odor or seeping
odor. drainage.

Evaluation of outcome objectives: Patients blood pressure did not improve but was below 160 for the systolic
pressure. Patient did not have worsening swelling in their extremities and vitals were stable throughout day of
care. All pulses were palpable at +2, so the goals were partially met.

Problem # ___8____: Impaired Skin Integrity

General Goal: Preventing skin breakdown
Predicted Behavioral Outcome Objective (s): The patient will…… not have worsening skin breakdown on
coccyx area of stage 2 and will show no signs of infection surgical sites.

on the day of care.

Nursing Interventions Patient Responses

1. Apply hydrocortisone cream to coccyx 1. Area did not worsen on day of shift
Wound assessment stage 2 was bruised like day before.
2. q2h turn 2. No skin breakdown
3. Apply dressing to coccyx 3. Dressing clean/dry/and intact
4. Assess for signs of infection like 4. No infection, skin bruised, clean/dry
redness around pressure wound
5. Measure area for progression of wound 5. Wound did not get bigger
6. Check dressing of amputation 6. Dressing clean, dry, and intact
7. Move ETT position q2h 7. No skin abrasion on lips
8. Bathe patient 8. Skin clean dry and intact
Evaluation of outcome objectives: Patient was able to maintain adequate skin hygiene with help of family
and nurses. The pressure wounds did not worsen over the shift and there was no skin breakdown on the lips
from the ETT. Outcome Met.

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