1

Taylor Siefke
Heidi Alflen
Critical Care

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- Imbalanced Key Problem- Oxygen Key Problem- Heart in

nutrition dependent Afib

Key Problem- Poor skin

Key Problem- Decreases Reason for Needing Health Care: integrity
lung expansion, shallow Pneumonia and hemoptysis
breathing

Key Problem- Fatigue Key Problem- Input and Key Problem- Impaired
output gas exchange

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

 2

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.

#1 Key Problem/ND: #4 Key Problem/ND: #5 Key Problem/ND:

Ineffective Airway Clearance r/t Decreased cardiac output r/t Fluid volume overload r/t AKI
Hemoptysis heart failure and CHF
Supporting Date: Supporting Data: Supporting Data:
Blood tinged sputum Pacemaker- AICD Edema in ankles bilaterally 2+
Breath sounds diminished with Rhythm- A-fib pitting
rhonchi S1 and S2 +murmur Urine output in 24 hrs-
RBC- 3.54 Coumadin d/t A-fib 110mL
Hgb-10.3 PT- 11.7, INR-1.1 Bun- 68 and creatinine- 1.47
Hct- 30.8 HR- 65 both elevated
BP-112/67
MAP- 65
Edema in lower extremities
bilaterally

Key Problem/ND:
#2 Impaired Gas Exchange r/t #6 Key Problem/ND:
pneumonia Imbalanced Nutrition r/t Less
Supporting Data: than body requirements
WBC- 20.1 Supporting data:
Reason For Needing Health Care
Neutrophils- 97 Admitted weight- 55.4 kg
(Medical Dx/ Surgery):
Na- 130 Weight on 10/29/19-51 kg
Hemoptysis
SPO2- 90-93 with O2- 9L NC Pt. NPO
Community Acquired Pneumonia
10/19/19: ABGs Abdomen- soft, round, non-
Vasculitis
pH- 7.48, PaCO2-27.8, PO2-47, tender
78 year old male, Full Code
HCO3- 21= Uncompensated Active bowel sounds
Key Assessments:
Respiratory Alkalosis Sore throat
Vital signs, focus on respiratory and cardiac
Chest x-ray 10/19/19- Oral thrush
functions
Multifocal airspace disease, new Calcium- 7.8 low
Allergies: None Known
in the right upper lobe Phosphate- 4.0
Vapotherm stopped on 10/27 Mag- 2.9
CPAP at night

#3 Key Problem/ND: #8 Key Problems/ND #7 Key Problem/ND:

Ineffective breathing pattern r/t Fatigue r/t vasculitis and Impaired skin integrity r/t
decreased lung expansion pneumonia wound
Supporting data: Supporting Data: Supporting Data:
Respirations ranged from- 16-20 Generalized weakness Wound on coccyx
Rhonchi bilaterally Limited movement Draining serosanguineous fluid
Decreased breath sounds Muscle pain Pain at a 9 in buttocks
bilaterally Jaw pain Skin warm, extremities cold
Productive cough, blood tinged Give Tylenol Q 4hrs PRN
Chest x-ray on 10/29/19-
increasing infiltrates
Interstitial pulmonary fibrosis

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

 3

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: Ineffective Airway Clearance r/t hemoptysis
General Goal: Increased Airway Clearance and no hemoptysis

Predicted Behavioral Outcome Objective (s): The patient will not cough up any more blood-tinged sputum by
the end of the shift.

on the day of care.

Nursing Interventions Patient Responses

1. Assess the rate, rhythm and depth 1. RR- 16-20, regular, shallow
of respiration breaths
2. Assess cough effectiveness and 2. Pt is coughing up bloody tinged
productivity sputum
3. Auscultate lungs 3. Diminished and Rhonchi
bilaterally
4. Assess patients hydration status 4. 0.9 NS continuously at 75mL/hr
5. Elevate head of bed 5. HOB was elevated 30 degrees
6. Suction PRN 6. Pt did not need suctioned
7. Teach pt proper deep breathing 7. Pt understood spirometer
exercises
8. Humidify Oxygen 8. Humidified O2 at 9L NC

Evaluation of outcome objectives: Patient still continues to cough up blood tinged sputum. Goal not met.

Problem # 2: Impaired Gas Exchange r/t pneumonia

General Goal: Increase Gas Exchange

Predicted Behavioral Outcome Objective (s): The patient will maintain a saturation of 90% or above on 9L of
oxygen NC on the day of care.

Nursing Interventions Patient Responses

1. Assess mental status 1. Pt was alert and oriented x4

2. Monitor Vitals 2. T-97.7, P- 65, BP-112/67, RR-16-20
SPO2- 90-93
3. Assess skin for cyanosis 3. Skin was pink and warm, extremities
were cold and pale
4. Assess chest x-ray 4. 10/29/19- increasing infiltrates
5. Elevate HOB 5. HOB was elevated at 30 degrees
6. Assess breath sounds 6. Diminished and rhonchi bilaterally
7. Assess for S&S of O2 toxicity 7. No S&S of oxygen toxicity noted
8. Assess anxiety level 8. Pt appeared relaxed and calm
Evaluation of outcome objectives: Patient maintained a saturation of 93% while on 9L O2 NC. Goal met.

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

 4

Problem # 3: Ineffective breathing pattern r/t decreased lung compliance

General Goal: Increase Lung Compliance

Predicted Behavioral Outcome Objective (s): The patient will maintain a respiration rate of 12-20 on the day
of care.

Nursing Interventions Patient Responses

1. Assess RR 1. RR ranged from 16-20

2. Observe breathing pattern 2. Shallow regular breathing
3. Assess for use of accessory muscles 3. No use of accessory muscles
4. Observe for flaring of nostrils 4. Nostrils were not flaring
5. Auscultate lungs 5. Diminished with rhonchi bilaterally
6. Move patient every 2 hrs 6. Pt moved from bed to chair
7. Suction PRN 7. Pt did not need suctioned
8. Teach pt deep breathing techniques 8. Pt understands spirometer
Evaluation of outcome objectives: Patients RR ranged from 16-20 on day of care. Goal met.

Problem # 4: Decreased cardiac output r/t Heart Failure

General Goal: Maintain Cardiac Output

Predicted Behavioral Outcome Objective (s): The patient will have no significant changes on EKG and vital
signs will stay within defined limits on the day of care.

Nursing Interventions Patient Responses

1. Assess vital signs 1. T-97.7, P- 65, BP-112/67, RR-16-20

SPO2- 90-93
2. Listen to heart 2. S1 and S2 heard+ murmur
3. Monitor EKG strip 3. A-fib with
4. Administer anticoagulants 4. Coumadin ordered
5. Monitor INR and PT 5. INR- 1.1, PT- 11.7
6. Administer antihypertensive 6. Metoprolol ordered
Evaluation of outcome objectives: Patients vital signs remained WDL and there were no significant changes
on the EKG. Goal met.

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

 5

Problem # 5: Fluid Volume Overload r/t AKI and CHF

General Goal: Decrease Fluid

Predicted Behavioral Outcome Objective (s): The patient will have a urine output of 30mL per hour
on the day of care.

Nursing Interventions Patient Responses

1. Assess urine 1. Yellow and clear

2. Assess Bun and Creatinine 2. BUN-68, Creatinine- 1.47
3. Intake and Output 3. Intake- 450 IV fluids (NPO), Output-
30mL (6hrs)
4. Assess H&H 4. Hgb- 10.3, Hct- 30.8
5. Assess BP 5. 112/67
6. Assess Edema 6. Lower extremity edema bilaterally
7. Daily Weight 7. Prior day weight- 52kg, day of care-
51 kg
Evaluation of outcome objectives: Patients output was 30mL in 6 hrs, goal not met.

Problem # 6: Imbalanced Nutrition r/t Less than body requirements

General Goal: Improve nutritional status

Predicted Behavioral Outcome Objective (s): The patients status will change from NPO to normal diet on day
of care.

Nursing Interventions Patient Responses

1. Assess bowel sounds 1. Active bowel sounds

2. Palpate abdomen 2. Round, soft and non-tender
3. Assess weight 3. Prior day weight- 52kg, day of care-
51 kg
4. Intake and Output 4. Intake- 450mL IV fluids (NPO),
Output- 30mL (6hrs)
5. Assess electrolytes 5. Na- 130 (high), Ca- 7.8 (low), Phos-
4.0(normal), Mag- 2.9 (high)
Evaluation of outcome objectives: Patient’s diet did not change during day of care. Goal not met.

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

 6

Problem # 7: Impaired skin integrity r/t wound

General Goal: Protect wound and promote healing

Predicted Behavioral Outcome Objective (s): The patient will turn every 2 hrs
on the day of care.

Nursing Interventions Patient Responses

1. Assess wound drainage 1. Serosanguineous fluid

2. Reposition pt 2. Pt sat in recliner
3. Assess H&H 3. Hgb- 10.3, Hct- 30.8
4. Risk for infection 4. Keep wound clean and protected
5. Acute pain 5. Administer Tylenol q 4 hrs
Evaluation of outcome objectives: The patient was repositioned every 2 hrs. Goal met.

Problem # 8: Fatigue r/t Vasculitis and Anemia

General Goal: Improve strength

Predicted Behavioral Outcome Objective (s): The patient will walk 10 steps down hall
on the day of care.

Nursing Interventions Patient Responses

1. Monitor RBCs, H&H 1. RBC-3.54, Hct-30.8, Hgb-10.3

2. Monitor electrolytes 2. Na- 130 (high), Ca- 7.8 (low), Phos-
4.0(normal), Mag- 2.9 (high)
3. Assess anxiety 3. Pt. seems calm and relaxed
4. Assess the pts ability to perform ADL’s 4. Pt. needs assistance with almost
with everything
5. Assess blood glucose 5. 102 (a little high)
6. Assess oxygen saturation 6. Ranges from 90-93 on 9L O2 NC
Evaluation of outcome objectives: Patient did not walk 10 steps on day of care he only walked from his bed
to the recliner in his room. Goal not met.

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