Nursing Process: Clustering Data

Group your abnormal patient assessment data to identify key problem areas to become nursing diagnoses
Key Problem: Key Problem: Key Problem: Key Problem:

Abnormal Assessment Data: Abnormal Assessment Data: Abnormal Assessment Data: Abnormal Assessment Data:
 Nursing Process: Nursing Diagnosis
Concept Map and Prioritization
Problem Area:
Problem Area:
Priority No. 2
Priority No. 1
Nursing Diagnosis:
Nursing Diagnosis:
Patient Initials:

Risk for bleeding R/T medications

Ineffective breathing pattern R/T
pulmonary embolism ASB SaO2,
restlessness, confusion, vital signs.
Age:

Diagnosis on admission:
Problem Area: Problem Area:
Priority No. 3 Priority No. 4
Nursing Diagnosis: Nursing Process: Nursing Care Plan Nursing Diagnosis:

Impaired gas exchange R/T decrease

Pain R/T surgery and complications pulmonary perfusion associated with
ASB chest pain and being treated with obstruction ASB confusion, SaO2, ABG.
morphine sulfate.

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GTNI: NU 102 Adult of Nursing Practice: Clinical Package
 Primary Nursing Diagnosis (Priority 1):
Primary Nursing Diagnosis (Priority 2):

Risk for bleeding

Expected R/T medications
Outcomes/Goals: Evaluation of outcome for this shift:
Outcome for this shift:

Expected Outcomes/Goals:
Overall Goal: Evaluation of outcome for this shift:
Outcome for this shift:
The nurse will manage and minimize bleedingRationale
Interventions episodes at the Evaluation of Intervention
end of the shift.
(Plan of nursing management for this (Why the intervention should be undertaken – (How the patient responded to
Overall Goal:
diagnosis) information from acceptable resource) the intervention)

Interventions Rationale Evaluation of Intervention

(Plan of nursing management for this (Why the intervention should be undertaken – (How the patient responded to the
diagnosis) information from acceptable resource) intervention)
Carful monitoring allows early detection of
Monitor surgical sit for bleeding. complications

Use electric shaver instead of decent It is risk for injury and lead to bleeding
razor.

Use a soft bristled toothbrush. It is risk for injury and lead to bleeding

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GTNI: NU 102 Adult of Nursing Practice: Clinical Package
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GTNI: NU 102 Adult of Nursing Practice: Clinical Package