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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

1. Ineffective Airway 4. Impaired renal function 3. Anxiety r/t paralysis and
Clearance r/t trach/vent and r/t ESRD vent
thick secretions.

Key Problem
Key Problem Reason for Needing Health Care 2. Risk of clotting r/t A. fib
5. Risk for Impaired Tissue and immobility
Integrity r/t
paralysis/immobility and
anemia

Key Problem Key Problem Key Problem

6. Powerlessness r/t
paralysis

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

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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
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.

#2 Key Problems/ND: Risk of

#1 thrombus formation

Key Problem/ND: Ineffective
airway clearance
Supporting Data:
Tracheostomy to vent
Diminished breath sounds in all lobes
Rhonchi auscultated in lower lobes
bilaterally
History of COPD
Not breathing above vent; VR and
RR both 18
Thick yellow sputum requiring
suctioning hourly
Chest X-ray on 10/12 showed
bilateral pneumonia
Brovana 15mcg BID nebulizer
Pulmicort 500mcg BID nebulizer
Xopenex 0.63mg Q6 nebulizer
Supporting Data:
#3 Key Problem/ND: Anxiety r/t
History of A. fib and HTN
mechanical ventilation and
History of smoking and alcoholism
paralysis
Quadriplegic
Continuous heparin IV drip
Supporting Data:
Turn Q2
SBP > 150
3+ pitting edema in RUE
Pain rated 9/10
1+ non-pitting edema in BLE
Major surgical complications
10/10 – non-occlusive DVT in R
Restlessness in bed
basilic vein
Mouthing “take it off” when
gesturing to tracheostomy tube
Mouthing “I can’t breathe”
repeatedly
NPO for several days
Reason For Needing Health Care
Fentanyl IV Q4 PRN
(Medical Dx/ Surgery):
Quadriplegia following odontoid screw
removal surgery
Anemia due to end-stage renal disease
A. fib, hypertension, COPD, Hepatitis C
66-year old male. DNR-CCA

Key Assessments: Focus on neurologic

function/peripheral sensation and respiratory
#5
status.

#4 Key Problem/ND: Impaired Allergies: Levaquin, Penicillins, Tetanus Key Problem/ND: Risk for impaired
renal function toxoids tissue integrity

Supporting Data: Supporting Data:

Hx of end-stage renal disease Quadriplegic
Anuric #6 Key Problem/ND: Turn Q2
Hemodialysis T, TH, S Powerlessness Anemia r/t ESRD
BUN 42 -RBC 2.22
Creatinine 4.5 Supporting Data: -Hgb 7.0
Albumin 3.0 Unable to verbally -Hct 21.1
Anemia communicate d/t tracheostomy Epoetin alfa 3.720 units SQ
-RBC 2.22 Unable to have PO food/fluids Tracheostomy
-Hgb 7.0 New onset of quadriplegia PEG tube
Lack of control over situation 2 chest tubes removed on 10/8
Restlessness in bed Dialysis fistula R arm
Incontinent of bowels Central access dialysis catheter L
SBP >150 femoral
Malnutrition r/t NPO status
Step 3: Draw lines between related problems. Number boxes as you prioritize problems.
Hx of smoking
Edema in RUE and BLE

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

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LASTLY- label the problem with a nursing diagnosis.

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # __1_____: Ineffective airway clearance
General Goal: Patient will maintain a clear airway.

Predicted Behavioral Outcome Objective (s): The patient will exhibit clear breath sounds and tolerate
trach suctioning every hour on the day of care.

Nursing Interventions Patient Responses

1. Auscultate lung sounds Q2 1. Rhonchi auscultated

2. Suctioning trach hourly 2. Tolerated; thick, yellow sputum
3. Continuous SpO2 monitoring 3. SpO2 remained >96%
4. Neuro status checks Q4 4. No changes in neuro status
5. Pulmicort 500mcg nebulizer BID 5. Tolerated well
6. Brovana 15mcg nebulizer BID 6. Tolerated well
7. Xopenex 0.63mg nebulizer Q6 7. Tolerated well
8. HOB >30 degrees

Evaluation of outcome objectives: Outcome partially met. The patient tolerated tracheostomy suctioning
hourly and secretions were cleared. Rhonchi were still auscultated in lower lobes bilaterally, and breath
sounds were diminished in all lobes. Will continue to monitor status.

Problem # __2_____: Risk of thrombus formation

General Goal: Patient will be free from thrombus formation.
Predicted Behavioral Outcome Objective (s): The patient will exhibit capillary refill <3 seconds and
palpable pulses in all extremities on the day of care.

Nursing Interventions Patient Responses

1. Palpate radial and pedal pulses Q2 1. Radial pulses 3+ and pedal pulses 2+
2. Assess cap refill Q2 2. Cap refill <3 seconds all extremities
3. Assess for new redness or swelling 3. No new redness or swelling observed
4. Heparin IV continuous drip 8.5ml/hr 4. Tolerated well
5. Palpate extremities for warmth Q2 5. No new warm areas observed
6. Perform passive ROM exercises 6. Tolerated well
Evaluation of outcome objectives: Outcome met. No new evidence of clot formation was observed on the
day of care. Capillary refill was <3 seconds and strong pulses were palpable in all extremities.

Problem # __3__: Anxiety r/t mechanical ventilation and paralysis

General Goal: Patient will be free from anxiety.

P.Predicted
Schuster, Concept
Behavioral Mapping:
Outcome A Critical
Objective(s): Thinking
Patient Approach,
will exhibit Davis, 2002.
calm behaviors and report pain level <5/10
on the day of care.
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1. Fentanyl IV Q4 PRN 1. Pain level decreased from 9 to 7/10

2. Turn/reposition Q2 2. Tolerated well
3. Dim lighting 3. Responded well to lights being off
4. Calm music playing on TV 4. Responded well
5. Trach suctioning hourly 5. Tolerated well; secretions cleared
6. Verbally reassure patient when in room 6. Patient still anxious and restless.

Evaluation of outcome objectives: Outcome not met. Patient still restless and agitated in bed. Repeatedly
mouthing “I can’t breathe” and asking to be taken off the vent. Reports pain level 7/10, even with
medication. Will continue to monitor.

Problem # __4__: Impaired Renal Function

General Goal: Patient will maintain adequate renal functioning.
Predicted Behavioral Outcome Objective(s): Patient will maintain BP within normal limits and exhibit
peripheral edema no worse than 1+ on the day of care.

Nursing Interventions Patient Responses

1. Check am BUN and creatinine 1. Elevated - BUN 42 and Creatinine 4.5

2. Assess peripheral edema Q2 2. 1+ edema in BLE; 3+ edema in RUE
3. Assess BP hourly 3. BP improved from 157/82 to 127/91
4. Assess neuro status Q4 4. No changes in neuro status
5. Check daily weight 5. 166lbs; prior weight of 165lbs
6. Elevate arms and legs with pillows 6. Tolerated well
Evaluation of outcome objectives: Outcome partially met. We were able to get BP under control with pain
meds and comfort measures. 3+ pitting edema still present in RUE; arm was elevated with 2 pillows.
Patient in end-stage renal failure. Will continue to monitor for changes.

Problem # __5__: Risk for impaired tissue integrity

General Goal: Patient will maintain appropriate skin integrity

Predicted Behavioral Outcome Objective(s): Patient will exhibit no new pressure ulcers on the day of care.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Nursing Interventions Patient Responses

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1. Turn and reposition Q2 1. Tolerated well

2. Elevate heels off bed 2. Tolerated well. Heels boggy
3. Assess skin for new redness Q2 3. No new red areas noted
4. Assess lines and drains Q2 4. No new drainage, bleeding, or redness
5. Assess pulses and cap refill Q2 5. Cap refill <3 seconds, pulses palpable

Evaluation of outcome objectives: Outcome met. Patient developed no new pressure injuries on the day of
care. Will continue to turn Q2, elevate heels, and assess high pressure areas frequently.

Problem # __6__: Powerlessness

General Goal: Patient will be free from powerless feeling and have sense of control over care.

Predicted Behavioral Outcome Objective(s): Patient will demonstrate understanding of rationale regarding
care by responding appropriately to yes or no questions.

Nursing Interventions Patient Responses

1. Educate on reason patient is ventilated 1. Patient asking to be taken off vent

2. Listen to patient concerns 2. Anxious & irritated with situation
3. Ask yes or no questions to assess understanding 3. Patient not responding to questions
4. Anticipate comfort needs 4. Tolerated well

Evaluation of outcome objectives: Outcome not met. Patient not cooperating with questions. Restless
movements and refusing vent despite explanation of the necessity of it. Will continue to find better ways
to communicate and allow patient to express his needs.

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