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ASHLEY WOLANZYK

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

Key Problem
Key Problem Reason for Needing Health Care
SEE OTHER ATTACHMENT PLEASE

Key Problem Key Problem Key Problem

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
tests, medical history, emotional state and pain. Also, identify key assessments that are
related to the reason for health care (chief medical diagnosis/surgical procedure) and put
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.
Don’t know where to put:
#1 Key Problem/ND # Key Problems/ND AST 1000
IMPAIRED GAS EXCHANGE ALT 365
Branden scale?
Supporting Data: Metabolic acidosis
-Pleural effusion
-ABG: pH 7.46, pCO2 31.5, pO2
148.5, HCO3 22.1
-Uncompensated respiratory
alkalosis
-Extensive infiltrate in right lung
-Pulmonary contusion due to CPR
-Vent A/C with FiO2 40, PEEP 8,
TV 450, rate 16

#2 Key Problem/ND:
#5 Key Problem/ND
IMPAIRED SPONTANEOUS
DECREASED CARDIAC
VENTILATION OUTPUT
-L radial pulse, bilat pedal and
Supporting Data: Reason For Needing Health Care PT pulses needed to use
-Acute respiratory failure (Medical Dx/ Surgery) Doppler to find
-On ventilator -syncope and collapse due to bilateral PE -Generalized edema, BUE and
-Mode A/C, TV 450, PEEP 8, -cardiac arrest 2x in ED with seizure-like BLE
rate 16, FiO2 40 activity -Hemorrhage d/t liver lac
-Diprivan (propofol) IV -liver lac with internal hemorrhage due to -Decreased RBC, HGB, HCT
CPR -levophed
-Mouth care q2h
-CTA chest showed straining of
-peridex -ex lap
R ventricle
-50 yo female, full code, allergy: penicillin -Wt gain 8 lbs since prior day
Kay assessments: VS with focus on -Anxiety
respiratory and cardiac -vasopressin

#3 Key Problem/ND #4 Key Problem/ND #6 Key Problem/ND


ACUTE PAIN R/T SURGICAL ANXIETY R/T CHANGE IN RISK FOR INFECTION
INCISION AND TRAUMA HEALTH STATUS -Surgical incision ex lap
-Ex lap on 9/30/18 -ETT -Intubated
-Incision left open for second sx -Restrained -Increases risk for VAP
-peridex
10/3/18 -Multiple lines, CVC triple -open abdomen for second
-Unable to verbalize discomfort lumen, introducer surgery upcoming
(ETT) -Cardiac arrest x2 -invasive procedures, suctioning,
-Liver laceration from CPR -Syncope and collapse CVC triple lumen, introducer
-Pulmonary contusion from -Acute pain, trauma -Malnutrition
CPR -Open abdomen -NPO
-Traumatic incident, syncope -Sedation, Diprivan (propofol) -Decreased Hgb
and collapse in parking lot

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


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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
General Goal: INCREASED GAS EXCHANGE

Predicted Behavioral Outcome Objective (s): The patient will maintain SpO2 >92% with normal heart
rate on the day of care.

Nursing Interventions Patient Responses

1. Monitor O2 saturation continuously 1. Patient was 98-100% on vent


using pulse oximetry 2. Lungs CTA bilaterally
2. Auscultate breath sounds q2h 3. No signs of distress noted
3. Watch for signs of distress like 4. Rate remained 16-18, rate set on vent
increasing anxiety or agitation at 16 breaths per minute
4. Monitor respiratory rate 5. Color appropriate for ethnicity with
5. Observe for cyanosis of skin vascular discoloration in BLE
6. Monitor client behavior and mental 6. Open eyes to speech, sedated
status (propofol), intubated UTA
7. Monitor effects of sedation on client orientation
respiratory pattern 7. Respiratory rate 16-18, vent rate set
at 16

Evaluation of outcome objectives: Goal met: the patient was 100% on ventilator (FiO2 40, TV 450, PEEP
8) and heart rate remained 86-98 bpm.

Problem # ___2___: IMPAIRED SPONTANEOUS VENTILATION


General Goal: MAINTAIN VENTILATION
Predicted Behavioral Outcome Objective (s): The patient will tolerate ventilator and have moist mucous
membranes on the day of care.

Nursing Interventions Patient Responses

1. Assess ventilator settings 1. A/C, rate 16, FiO2 40, PEEP 8, TV450
2. Administer sedatives to facilitate comfort/rest 2. Diprivan (propofol) at 5.2 mL/hr
3. Suction as needed and hyperoxygenate 3. Tolerated suctioning, scant amount of
secretions noted
4. Analyze ABG’s 4. pH 7.46, pCO2 31.5, pO2 148.5, HCO3 22.1
5. Move ETT to other side of mouth 5. Increase pt comfort, prevent skin
breakdown
6. Mouth care q2h 6. Tolerated mouth care, peridex, no signs of
discomfort
7. Assess bilateral breath sounds q2h 7. Lungs CTA bilaterally

Evaluation of outcome objectives: Goal met: the patient tolerated ventilation and exhibited moist
mucous membranes.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
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Problem # ___3___: ACUTE PAIN R/T SURGICAL INCISION AND TRAUMA


General Goal: DECREASED PAIN

Predicted Behavioral Outcome Objective (s): The patient will exhibit no signs of acute pain via 0 out of 10
on CPOT pain scale on the day of care.

Nursing Interventions Patient Responses


1. Determine if pt is in pain 1. Pt appears to be pain free, 0/10 on
2. Assess for pain routinely, q1h at the time of CPOT scale
VS 2. Pt continually scored 0/10, CPOT.
3. Identify a pain level goal 3. Maintain pain level < 2 on CPOT
4. Explain to client/family the pain scale.
management approach 4. Explained to pt and family that she
5. Administer medication as ordered is ordered fentanyl to help minimize
6. Treat pain in comprehensive manner pain and maximize comfort
7. Encourage nonpharmalogical pain relief 5. Fentanyl 5 mL/hr IV
6. Fentanyl administered
continuously, IV
7. Family present to soothe pt,
environmental stimuli minimized

Evaluation of outcome objectives: Goal met: the patient remained free of pain as evidenced by 0 on
CPOT scale.

Problem # ___4___: ANXIETY R/T CHANGE IN HEALTH STATUS


General Goal: DECREASE ANXIETY

Predicted Behavioral Outcome Objective (s): The patient will have VS that reflect baseline, and gestures
/facial expressions reflecting decreased distress on the day of care.

Nursing Interventions Patient Responses

1. Assess for physical reactions to anxiety 1. Pt did not exhibit any nonverbal
expressions indicating anxiety
2. Assure pt that feeling anxious is normal 2. Pt looked at me and moved hand
toward me.
3. Remove sources of anxiety 3. Medication to decrease pain, verbal
reassurance was acknowledged
with gesture “thumbs up”
4. Explain procedures beforehand 4. Pt nonverbal cue; she heard me
5. Use healing touch 5. Increased pt comfort level
6. Teach family signs of anxiety to report 6. Family verbalized understanding

Evaluation of outcome objectives: Goal met: the pt VS remained at baseline (aeb BP 118/61-135/65, HR
86-98 bpm, RR 16-18 per min) and she gestured with thumbs up and nods.

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


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Problem # __5__: DECREASED CARDIAC OUTPUT


General Goal: MAINTAIN CARDIAC OUTPUT

Predicted Behavioral Outcome Objective (s): The patient will maintain NSR and VS WNL on the day of
care.

Nursing Interventions Patient Responses


1. Assess BP, HR and rhythm q1h 1. BP 118/61-135/65, HR 86-98, NSR
2. Monitor daily weights 2. 10/1/18 191 lbs, 10/2/18 197 lbs
3. Monitor pulse oximetry 3. 98-100% on ventilator
4. Keep on bedrest 4. Pt remained sedated and in bed
5. Provide restful environment (dim lights, 5. Increased pt comfort, less restless
minimize sounds) 6. intake 1455mL, output 200 mL
6. Monitor I/O 7. electrolytes WNL, BNP high 3982,
7. Monitor lab values troponin <0.1
8. Monitor for s/s of cardiogenic shock 8. Pt did not exhibit hypotension,
decreased pulses, pulmonary congestion,
or clammy skin

Evaluation of outcome objectives: Goal met: the patient VS were WNL (BP 118/61-135/65, HR 86-98
bpm, RR 16-18 per min) and NSR.

Problem # ___6___: RISK FOR INFECTION


General Goal: NO S/S OF INFECTION

Predicted Behavioral Outcome Objective (s): The patient will not exhibit signs of infection (elevated
temperature, elevated WBCs) on the day of care.

Nursing Interventions Patient Responses

1. Observe for redness, warmth, increased temp 1. No redness/warmth, temp 99.6-100.8F


2. Use oral thermometer to check temp q1h 2. Temp 99.6-100.8F
3. Note lab values 3. WBC 14.6, albumin low 2.0, total protein low 3.8
4. Assess skin q2h 4. Skin is cool, dry, turgor is good.
5. Perform hand hygiene 5. Foam in, foam out, decrease pt risk for infection
6. Follow standard precautions 6. Wore gloves during contact with body fluids,
decrease pt risk for infection
7. Perform hygiene for patient 7. Pt tolerated oral care q2h, a bath, linen change,
and peri care

Evaluation of outcome objectives: Goal not met: pt had elevated temperature (99.6-100.8F) and elevated
WBCs of 14.6

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