1

Data don’t
Step 2. Support problems with clinical patient data, including abnormal physical know where
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab to put in
tests, medical history, emotional state and pain. Also, identify key assessments that are boxes:
related to the reason for health care (chief medical diagnosis/surgical procedure) and put
#1
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. #2 Ineffective airway clearance
related to presence of artificial #3 Risk for decreased cardiac
Impaired gas exchange related to output related to mechanical
ventilator/perfusion imbalance as evidence by airway as evidence by abnormal
breath sounds, inability to ventilation
abnormal arterial blood gas values.  Blood pressure – 93/54
remove airway secretions, and
 Intubated by ETT  MAP – 70
absent cough.
 ABG: pH – 7.36, PO2 – 77.9, PCO2 – 53.3,  Heart Rate – 77
HCO3 – 29.8  Coarse rhonchi, and
diminished breath sounds at  Edema present
 Compensated respiratory acidosis generalized throughout,
bases present via
 FiO2 – 0.4 non-pitting
auscultation
 PEEP – 5  Right radial pulse +1, L
 ETT requiring suctioning
 Diminished breath sounds every 1-2 hours Brachial Pulse +1, Pedal
 Bilateral pleural effusions and pulmonary  Thick clear to cloudy pulses +1, bilaterally
edema per chest x-ray secretions and sputum  Skin warm and dry
 SpO2 – 95-100%  Duoneb via inhalation  NSR
 Abnormally low hemoglobin, hematocrit  History of COPD and
and red blood cell levels smoking
 Hg – 8.2 Hct – 27%  Pulmonary edema and
effusion via chest x-ray Dysfunctional gastrointestinal
#4 Delayed surgical recovery related to #5
 Patient in semi-fowlers motility related to surgery as
extensive surgeries as evidence by position
interrupted healing of surgical area evidence by abdominal
distention, absence of flatus,
 Open wound due to abdominal
and hypoactive bowel sounds
dehiscence and evisceration Reason For Needing Health Care  Hypoactive bowel sounds
 Bogota bag, dry dressing, and (Medical Dx/ Surgery)
binder applied to abdomen  Bogota bag intact and
Abdominal wound dehiscence and
applied to midline
 No redness in periwound area evisceration, r/t pancreatoduodenectomy.
abdomen surgical wound
 Patient normothermic, Staged abdominal closure with use of bogota
 Gastric residual 200 mL
temperature - 98.2 bag, dry dressing, and binder.
per NG
 Moderate amount of 55 year old female, full code.
Key assessments:  Nimbex IV (paralytic)
serosanguinous drainage via JP
drain Respiratory system, integumentary system,  Opioid pain medication
Fentanyl IVand
 Wound pink and moist and gastrointestinal system
Oxycodone PO via NG
 White blood cells - 13.4 Allergies: Penicillin
 Creon
 Obese BMI: 28.6 (r/f for wound
 Reglan, Zofran
dehiscence)
#6  Protonix

Imbalanced nutrition: less than body requirements
#7 Risk for acute confusion related
related to inability to ingest food by mouth aeb
to fluctuation in sleep wake
ETT intubation, NG tube, TPN, low protein and #8 Impaired verbal communication
cycle
calcium levels
 Propofol IV sedation related to physical barrier aeb
 Albumin – 3.3
 Nimbex IV paralytic ETT intubation
 Total protein – 5.4  Cannot speak due to ETT
 Fluctuating level of
 Calcium – 8.4  Expresses communication
consciousness
 Potassium – 3.5
 Fluctuating BIS score through facial expressions
 Phosphate – 4.8 and nodding
 Bilateral 2 point restraints
 History of high blood sugar possibly related to  Possible alteration in
 Ativan PRN
pancreatoduodenectomy, blood glucose – 166 perception of verbal
 History of bipolar disorder
 Insulin – Humalog/Lantus communication
 History of self extubation
 Dextrose PRN  History of meniere's
 NG @ 20 mL/hour disease, can cause hearing
 TPN @ 50 mL/ hour loss
 Obese BMI: 28.6
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
 2

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 # 1: Impaired gas exchange related to ventilator/perfusion imbalance as evidence by abnormal arterial
blood gas values
General Goal: Increase gas exchange

Predicted Behavioral Outcome Objective (s): The patient will……

Patient maintains optimal gas exchange as evidenced by oximetry and arterial blood gases within normal
range on the day of care.

Nursing Interventions Patient Responses

1. Assess respiratory rate, depth, 1. Patient had regular rate, depth

and effort and effort
2. Assess arterial blood gases 2. Pt was in compensated
3. Assess Hemoglobin and respiratory acidosis
Hematocrit lab values
4. Monitor SpO2 3. Hemoglobin and hematocrit
5. Auscultate lung fields for values were low
presence of adventitious sounds 4. SpO2 was maintained between
6. Monitor daily chest x-ray 95-100%
7. Elevate HOB 5. Pt had rhonchi present
8. Suction as necessary 6. Pt Daily CXR showed pleural
effusion
7. Pt respiratory status improved
with elevation of HOB (enhanced
chest expansion)
8. Pt had moderate amount of thick
secretions
Evaluation of outcome objectives:
Pt maintained normal pulse oximetry range, but arterial blood gases were not within normal limits
(compensated respiratory acidosis)

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

 Problem # 2: Ineffective airway clearance related to presence of artificial airway as evidence by abnormal
breath sounds, inability to remove airway secretions, and absent cough. 3
General Goal: Increase Airways Clearance

Predicted Behavioral Outcome Objective (s): The patient will……

Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of
respirations on the day of care.

Nursing Interventions Patient Responses

1. Auscultate lungs for presence of normal 1. Pt had rhonchi present

or adventitious breath sounds
2. Assess respirations 2. Pt maintained eupnea
3. Note presence of sputum 3. Thick secretions were present with suctioning
4. Assess hydration status 4. Pink and moist mucus membranes, elastic skin turgor
5. Perform suctioning as necessary 5. Pt required suctioning approximately every 2 hours
6. Hyper oxygenate before suctioning 6. Pt tolerated hyper oxygenation
7. Administer prescribed bronchodilators 7. Pt tolerated nebulizer treatment per respiratory therapy
8. Reposition pt every 2 hours 8. Pt tolerated reposition, enhancing lung expansion
Evaluation of outcome objectives: Patient maintained clear, open airways with occasional presence of
rhonchi, which cleared with suctioning on day of care. Pt maintained normal rate and depth of respirations on
the day of care.

Problem # 3: Risk for decreased cardiac output related to mechanical ventilation

General Goal: Maintain adequate cardiac output
Predicted Behavioral Outcome Objective (s): The patient will……
Patient demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within
normal parameters for patient, as well as strong peripheral pulses on the day of care.

Nursing Interventions Patient Responses

1. Assess skin color, temperature, and moisture 1. Pt skin was pale, warm, and dry
2. Assess heart rate and rhythm 2. Pt heart rate was within normal range most of day 77-110,
regular rhythm, NSR
3. Assess blood pressure 3. Pt maintained lower than average blood pressure 91/53
MAP 62
4. Assess peripheral pulses and capillary refill 4. Peripheral pulses were 1+ and capillary refill <3 seconds
5. Assess presence of edema 5. Generalized non pitting edema was present
6. Monitor urinary output 6. Urinary output was adequate > 30 mL/hour
7. Auscultate heart sounds 7. Presence of S1 and S2
8. Monitor fluid balance and weight gain 8. Pt fluid balance was +530 for the previous 24 hour period

Evaluation of outcome objectives: Patient demonstrated adequate cardiac output as evidenced by blood
pressure, pulse rate and rhythm within normal parameters for patient, as well as presence of peripheral pulses
on the day of care

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

 Problem # 4: Delayed surgical recovery related to extensive surgeries as evidence by interrupted healing of 4
surgical area
General Goal: Improve wound healing

Predicted Behavioral Outcome Objective (s): The patient will……

Surgical area will show evidence of healing; no redness, induration, or drainage present on the day of care.

Nursing Interventions Patient Responses

1. Assess surgical site and periwound area 1. Pt surgical sign was open, pink and moist; covered with a bogota bag, abd
pad, and a binder
2. Assess surgical site drainage 2. Pt had 2 JP drains with a moderate amount of serosanguinous drainage
3. Assess patient’s risk factors for delayed wound healing 3. Pt’s risk factors were obesity and high blood glucose levels
4. Assess patient’s dietary status 4. Pt was tube fed via NG with added protein, 1.2 cal/mL
5. Maintain control of blood glucose levels 5. Pt blood glucose was 145-167 on day of care, insulin administered every 4 hrs
6. Maintain use of aseptic technique with wound care 6. Pt tolerated aseptic technique with would care
7. Change surgical dressings at appropriate intervals 7. Pt tolerated wound assessments and dressing changes

Evaluation of outcome objectives:

Surgical area showed evidence of healing; no redness, induration, or drainage present on the day of care.

Problem # 5: Dysfunctional gastrointestinal motility related to surgery as evidence by abdominal distention,

absence of flatus, and hypoactive bowel sounds
General Goal: Restoration of normal peristalsis
Predicted Behavioral Outcome Objective (s): The patient will……
Have normal bowel sounds, passage of flatus, and no abdominal distention on the day of care.

Nursing Interventions Patient Responses

1. Inspect abdomen 1. Abdomen was rounded and distended
2. Auscultate bowel sounds and passage of flatus 2. Bowel sounds were hypoactive, no passage of flatus noted
3. Palpate abdomen 3. Abdomen was soft, but firm
4. Monitor NG residual 4. Pt had NG residual of 150 mL
5. Administer Colace 5. Pt was administered Colace via NG to soften stool and reduce staining d/t constipation
6. Administer protonix daily 6. Pt was administered protonix to decrease GI acid secretions
7. Administer reglan per doctor’s orders 7. Pt was administered reglan to help increase gastric emptying
8. Administer Zofran prn for nausea 8. Pt was able to take Zofran prn for evidence of nausea r/t hypoactive GI tract

Evaluation of outcome objectives:

Pt had hypoactive bowel sounds, no known passage of flatus, and abdominal distention on the day of care.

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

 Problem # 6: Imbalanced nutrition: less than body requirements related to inability to ingest food by mouth
aeb ETT intubation, NG tube, TPN, low protein and calcium levels 5
General Goal: Improve nutrition status

Predicted Behavioral Outcome Objective (s): The patient will……

Take adequate amount of calories or nutrients, shows no signs of malnutrition on the day of care.

Nursing Interventions Patient Responses

1. Weigh patient daily 1. Pt weight on day of care was 172.9 pounds
2. Review protein lab values 2. Total protein – 5.4, albumin – 3.3 on day of care
3. Review electrolyte lab values 3. Calcium – 8.4, Potassium – 3.5, Phosphate – 4.8, Sodium – 150, Chloride – 108 on day of care
4. Offer supplemental protein 4. Pt tube feed was supplemented with protein
5. Monitor intake and output 5. Pt had and intake of 20mL/hour via NG, 1.2 cal/mL (576
calories in 24 hour period), also TPN @ 50/hour
6. Monitor NG residual 6. Ng residual was 150 mL on day of care
7. Provide appropriate oral hygiene. 7. Pt tolerated oral hygiene

Evaluation of outcome objectives:

Pt took an adequate amount of calories or nutrients between TPN and parenteral nutrition, considering low
activity level; pt shows signs of malnutrition as evidence by low Ca and protein levels

Problem # 7: Risk for acute confusion related to fluctuation in sleep wake cycle
General Goal: Decrease risk for acute confusion

Predicted Behavioral Outcome Objective (s): The patient will……

Have diminished episodes of delirium and demonstrate appropriate behavior on the day of care.

Nursing Interventions Patient Responses

1. Conduct an accurate mental/nuero status exam 1. Pt was unresponsive with intermittent responsiveness, at times (sedated)
2. Monitor lab values 2. Sodium – 150, which could contribute to confusion
3. Sedation vacation 3. Pt was responsive when sedation was temporarily discontinued
4. Orient patient to surroundings, staff, and activities as needed 4. Pt was oriented often, and before procedures and assessment
5. Provide safety needs 5. Side rails of bed were up x4, call light was in reach, and non-skin socks were
applied to decrease risk of patient injury
6. Avoid and limit the use of restraints if possible 6. Pt was restrained due to previous history of self extubation
7. Plan care that allows for appropriate sleep-wake cycle 7. Pt rested during after periods of care were completed

Evaluation of outcome objectives:

Pt had diminished episodes of delirium and demonstrated appropriate behavior on the day of care.

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

 6

Problem # 8: Impaired verbal communication related to physical barrier aeb ETT intubation
General Goal: Use of nonverbal communication/ alternative methods of communication

Predicted Behavioral Outcome Objective (s): The patient will……

Use a form of communication to get needs met and to relate effectively with people and her environment on
the day of care.

Nursing Interventions Patient Responses

1. Ascertain situations that may limit the patient’s ability to verbally communicate 1. Pt has ETT, with weaning sedation
2. Review history of neurological disease 2. Pt has history of meniere's disease which can cause hearing loss
3. Evaluate mental status, note presence of psychotic conditions 3. Pt has history of bipolar disorder, but not psychotic symptoms
were present
4. Assess the patient’s preferred language for verbal and written communication 4. The patients preferred language was English
5. Learn patient needs and pay attention to nonverbal cues. 5. Pt would maintain eye contract and move hands as a nonverbal cue
6. Place important objects within reach. 6. Call light was placed within reach, but pt was unable to use d/t restraints
7. Try to phrase questions requiring a “yes” and “no” answers 7. Pt was able to nod or shake head to answer simple questions

Evaluation of outcome objectives:

Pt used simple yes or no communication responses to get needs met and to relate effectively with people and
her environment on the day of care

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