NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
NURSING PROCESS TEMPLATE:
Assessment (Recognizing Cues)
Which patient information is relevant? What
patient data is most important? Which patient
information is of immediate concern? Consider
signs and symptoms, lab work, patient statements,
H & P, and others. Consider subjective and
objective data.
Analysis (Analyzing Cues)
Which patient conditions are consistent with the
cues? Do the cues support a particular patient's
condition? What cues are a cause for concern? What
other information would help to establish the
significance of a cue?
Analysis (Prioritizing Hypotheses)
What explanations are most likely? What is the most
serious explanation? What is the priority order for
safe and effective care?
Miguel a 60-year-old client arrives in the hospital
in a wheelchair accompanied by his daughter,
the patient verbalized “My chest hurts so much, I
can feel it up to my should and neck”. Upon
assessment his vitals are elevated, Blood
pressure – 170/110 mmHg, Heart rate –
120bpm, Respiratory rate – 25bpm,
Temperature of 100.4 0F. He describes the pain
9 out of 10. His jugular vein is distended and
upon touching he has a cool clammy skin.
Laboratory exams revealed CBC: WBC
5,600/mm3, Hg 15.2/dL, Hct 45%,
Plt320,000/mm3, Glu 110mg/dL, BUN 11mg/dL,
Crea 0.9mg/dL, ECG on going. Immediate
concern that should be address is the
respiratory rate and blood pressure, also the
main complaint which is chest pain.
The chief complaint is chest pain, and it is
supported by problem in vitals such as a high
blood pressure and respiratory rate. Distention
of jugular vein is also related to having problems
with the heart of with the circulation as having
pressure that radiates to shoulder and neck.
Glucose is relatively high and cool and clammy
skin is an initial response from having a 100.4 0F
body temperature.
Angina Pectoris (Chest Pain) a syndrome
characterized by episodes or paroxysmal pain
or pressure in the anterior chest
caused by insufficient coronary blood flow.
Physical exertion or emotional stress increases
myocardial oxygen demand, and the coronary
vessels are unable to supply insufficient blood
flow to meet the oxygen.
The priority in this case is to stop all activity or
sit/rest in semi fowler’s position for patient’s
comfort. First, identification of cause of the pain
is important as it will help to treat the signs and
symptoms. Addressing problem with circulation,
respiration and body temperature is must since it
contributes the most to the chief complaint.
Administration of oxygen, medication like
nitroglycerin, beta-blocker, ccb etc. as per
doctor’s order. And lastly is health education
about rest and exercise together with diet that
should be in low fat and high fiber.
Planning (Generate Solutions)
What are the desirable outcomes? What
interventions can achieve these outcomes? What
should be avoided? (SMART Planning- specific,
measurable, attainable, realistic/relevant, time-
restricted- Goal setting)
Implementation (Take actions)
How should the intervention or combination of
interventions be performed, requested,
communicated, taught, etc.? What are the priority
interventions? (Mark with asterisk)
After 8 hours of nursing intervention the patient
will:
✓ be free from pain as evidence by good
facial expression without grimace and a
score of 0 to 1 in the pain scale.
✓ maintain stable vitals as evidence by a
normal blood pressure, respiratory rate,
and heart rate.
✓ Demonstrate adequate perfusion as
evidence by warm and dry skin with
normal body temperature.
✓ maintain a relaxed body posture as
evidence by having a good breathing
pattern, being comfortable in his position
and being coherent.
✓ understand his condition by enumerating
exercise, food, rest, and mood that is
beneficial and bad to his condition.
*Assess frequently (15-30mins) for vital signs
and symptoms of pain such facial grimacing,
rubbing of neck and jaw, reluctance to move,
increased blood pressure, and tachycardia. Note
onset, duration, location, and pattern of pain.
Administer morphine and anti-coagulant as
prescribed.
*Administer sublingual nitroglycerin as ordered -
Advise the patient that if pain persists after
taking 3 sublingual tablets at 5 min interval the
doctor will be called.
Administer oxygen (2L/r) via nasal cannula as
ordered.
*Assist patient during activities especially when
standing from a sitting position. Orthostatic
hypotension leads to temporary decreased
cerebral perfusion.
*Provide health teaching to the patient and
family about planning activities and rest,
importance of emotional support and having a
correct diet with food and liquids that is low in fat
and high in fiber.
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Evaluation (Evaluating Outcomes)
What signs point to
improving/declining/unchanged status? What
interventions were effective? Are there other
interventions that could be more effective? Did the
patient’s care outlook or status improve?
Goal was met-
At the end of the shift:
The client’s pain was relieved as evidence by
good facial expression, decrease (0-1) pain
score and verbalizing comfort.
The client’s vitals stabilized as having BP of
120/80, HR of 70 and RR of 16.
Has adequate perfusion as evidence by having
warm and dry skin with 98.40F body
temperature.
The client was relaxed by having a good sit
posture, a normal breathing pattern and is
coherent with family and the nurse.
The client understands his condition as he
verbalized, he will stay away from smoking and
alcohol, plans to have adequate exercise and
rest and lastly to maintain a good diet the is high
fiber and low fat.
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Patient Information (SBAR, H&P)

S – Miguel a 60-year-old male arrive at the hospital with his daughter,

complaining of a severe chest pain that radiates to the shoulder and Main Concept
neck. The patient has high blood pressure, tachypneic, tachycardic and
has a cool clammy skin.
(Should be focus of below map)

B- patient is a smoker since teenager can consume from half to whole Acute pain related to decreased myocardial blood
pack of cigarette a day, consumes alcohol (beer 4-5 bottles) at least 3 flow as evidence by chest pain as patient
times a week. Moderately obese and has a sedentary lifestyle (cashier).
verbalized “My chest hurts so much; I can feel it up
A-Vitals revealed mostly elevated BP: 170/100, PR: 120bpm, RR: 25bpm, to my should and neck.”
T: 100.4 0F. He describes the pain 9 out of 10.

R-the patient need to relived chest pain, nitroglycerin or morphine can be

administered if prescribed and with the help of oxygen as well.

H-patient is a heavy smoker and alcoholic, experiences chest pain when

doing heavy work like lifting heavy boxes in the store.

P-Laboratory exams revealed CBC: WBC 5,600/mm3, Hg 15.2/dL, Hct 45%,

Plt320,000/mm3, Glu 110mg/dL, BUN 11mg/dL, Crea 0.9mg/dL. ECG is
ongoing.

CONCEPT MAP TEMPLATE:

Recognizing Cues (S&S) Disease Process/Pathophysiology/Risk Factors

Objective data: Patient verbalized ““My chest hurts so

much; I can feel it up to my should and neck”. He
describes the pain 9 out of 10.
Subjective data: Upon assessment client has high
blood pressure (170/110 mmHg), he experiences
tachycardia (HR-120bpm) and tachypnea (RR-25bpm).
He also had low fever (T-100.4 0F) and lastly, His
jugular vein is distended and upon touching he has a
cool clammy skin.
Angina Pectoris (Chest Pain) a syndrome characterized by episodes
or paroxysmal pain or pressure in the anterior chest caused by
insufficient coronary blood flow. Physical exertion or emotional
stress increases myocardial oxygen demand, and the coronary
vessels are unable to supply insufficient blood flow to meet the
oxygen.

Analyzing Cues/Concerns

Supporting
Distention of jugular vein is also related to having problems with the
heart of with the circulation as having pressure that radiates to
shoulder and neck. Glucose is relatively high and cool and clammy skin
is an initial response from having a 100.4 0F body temperature.

Concerning
Chest pain that is supported by problem in
vitals such as a high blood pressure, heart
rate and respiratory rate

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Prioritizing Hypotheses

1. 1. The chief complaint is chest pain, and it is supported by problem in vitals such as a high blood
pressure and respiratory rate. (Acute Pain)
2. Distention of jugular vein is also related to having problems with the heart of with the circulation
as having pressure that radiates to shoulder and neck. (Impaired gas exchange related to
2.
problem with perfusion)
3. Glucose is relatively high and cool and clammy skin is an initial response from having a 100.4
0F body temperature. (Fluid and electrolyte imbalance and decrease cardiac output)
3.

Generate Solutions/Outcomes/Interventions Taking Action – (How To)

SMART Planning
1.After 8 hours of nursing intervention the patient will:
➢ be free from pain as evidence by good facial
2.
expression without grimace and a score of 0 to
3. 1 in the pain scale.
➢ maintain stable vitals as evidence by a normal
4. blood pressure, respiratory rate, and heart rate.
➢ Demonstrate adequate perfusion as evidence
by warm and dry skin with normal body
5.
temperature.
➢ maintain a relaxed body posture as evidence
by having a good breathing pattern, being
comfortable in his position and being coherent.
➢ understand his condition by enumerating
exercise, food, rest, and mood that is beneficial
and bad to his condition.
1. *Assess frequently (15-30mins) for vital signs and symptoms of pain
such facial grimacing, rubbing of neck and jaw, reluctance to move,
2. increased blood pressure, and tachycardia. Note onset, duration,
location, and pattern of pain.
3. Administer morphine and anti-coagulant as prescribed.
*Administer sublingual nitroglycerin as ordered - Advise the patient
4. that if pain persists after taking 3 sublingual tablets at 5 min interval
the doctor will be called.
5.
Administer oxygen (2L/r) via nasal cannula as ordered.
Assist patient during activities especially when standing from a sitting
position. Orthostatic hypotension leads to temporary decreased
cerebral perfusion.
*Assist patient during activities especially when standing from a
sitting position. Orthostatic hypotension leads to temporary
decreased cerebral perfusion.

*Provide health teaching to the patient and family about planning

activities and rest, importance of emotional support and having a
correct diet with food and liquids that is low in fat and high in fiber.

Evaluating Outcomes

1. Goal was met-

At the end of the shift:

2.
The client’s pain was relieved as evidence by good facial expression, decrease (0-1) pain score and verbalizing comfort.
3.
The client’s vitals stabilized as having BP of 120/80, HR of 70 and RR of 16.

4. The client has adequate perfusion as evidence by having warm and dry skin with 98.4 0F body temperature.

5. The client was relaxed by having a good sit posture, a normal breathing pattern and is coherent with family and the nurse.

The client understands his condition as he verbalized, he will stay away from smoking and alcohol, plans to have adequate exercise and rest
and lastly to maintain a good diet the is high fiber and low fat.

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References:

Mayo Clinic. (2022, March 30). Angina - Symptoms and Causes. Mayo Clinic; Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/angina/symptoms-causes/syc-20369373

Watson, S. (2021, November 5). Angina. WebMD; WebMD. https://www.webmd.com/heart-

disease/heart-disease-angina

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