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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

Impaired gas exchange Ineffective airway Impaired spontaneous
clearance ventilation

Key Problem
Key Problem Reason for Needing Health Care Risk for infection
Impaired verbal ATV accident (trauma)
communication Intracranial hypertension
Subdural and epidural hematoma
Facial bone fracture
No bone flap on right side
Intubated
Acute respiratory failure
Pleural effusion

Key Problem Key Problem Key Problem

Risk for anxiety and Fear Risk for increase intracranial
pressure

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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.
#1 Key Problem/ND Data don’t know where to put in boxes: #2 Key Problem/ND
Impaired gas exchange  Low albumin levels Impaired spontaneous
 Elevated ALP and ALT ventilation
Supporting data:  Low RBCs, Hgb, and Hct
 Pleural effusion  Platelets have also been elevated Supporting data:
 Acute respiratory distress  No distinguished T wave  Patient on a ventilator
 FiO2, 80%  Pleural effusion
 SpO2 96% (with .80  Acute respiratory distress
FiO2)  Possible trauma to the
 Possible trauma to the chest
chest  Patient on a continuous
 PEEP of 8 Versed drip
 Patient was also on
Nimbex (paralytic)

#3 Key Problem/ND:
Risk for increase intracranial Reason For Needing Health Care #4
(Medical Dx/ Surgery) Key Problems/ND
pressure
17 y.o. male, Full code Ineffective airway clearance
Supporting data: ATV accident (trauma)
Intracranial hypertension Supporting data:
 Trauma to the head
Subdural and epidural hematoma  Possible trauma to chest
 Facial bone fracture
Facial bone fracture  Patient intubated
 Subdural hematoma
 Epidural hematoma No bone flap on right side
 Craniotomy x2 Intubated
Acute respiratory failure
 Bone flap removed to
Pleural effusion
decrease ICP
Key assessments:
VS with focus on respiratory and neuro
Allergies: No known allergies

#5 Key Problem/ND #6 Key Problem/ND #7 Key Problem/ND

Risk for infection Risk for anxiety and Fear Impaired verbal
communication
Supporting data: Supporting data:
 WBC: 11.8  Patient woke up from Supporting data:
 Increase temperature of paralytic state during shift  Patient intubated
100.6 degrees Fahrenheit  Patient did not know what  Patient being give
 Craniotomy had happened to him continuous Versed drip
 Multiple Bronchoscopy  Patient was restrained due to  Brain function unknown
 Bilateral chest tubes ET tube after increased
 Multiple invasive lines intracranial pressure
 Patient seemed to be
confused
Step 3: Draw lines between related problems. Number boxes as you prioritize problems.

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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 : Impaired Gas Exchange
General Goal: Increased Gas exchange

Predicted Behavioral Outcome Objective (s): The patient will maintain ABGs that are within normal limits,
also they will maintain an SpO2 of 88% or above on the day of care.

Nursing Interventions Patient Responses

1. Have a FiO2 level to adequately 1. Patient remained on a High FiO2

maintain SpO2 levels of (.80) throughout shift
2. Assess ABGs and SpO2 levels 2. ABGs normal, and maintain
3. Assess chest x-rays SpO2 levels above 94%
4. Elevate HOB to 30 degrees 3. X-ray normal
5. Assess for S/S of oxygen toxicity 4. Patients HOB elevated
5. No S/S of oxygen toxicity

Evaluation of outcome objectives:

Patient did well and maintained his SpO2 levels but did require a very high FiO2 (.80) to maintain that.

Problem # 2 : Impaired spontaneous ventilation

General Goal: Maintain ventilation
Predicted Behavioral Outcome Objective (s): The patient will tolerate the ventilator on current or improved
setting and maintain moist mucous membranes on the day of care.

Nursing Interventions Patient Responses

1. Monitor SpO2 1. Patient maintained an SpO2

2. Discontinue Nimbex above 94%
(Cisatracurium) 2. Patient regained muscular control
3. Titrate Versed (Midazolam) 3. Patient began to regain
4. Assess the ventilator settings consciousness
5. Mouth care q2hrs and prn 4. Ventilator settings maintained
5. Tolerated mouthcare

Evaluation of outcome objectives:

Patient did well on the ventilator but was on assist control so he was not able to take spontaneous breaths.
However, he did not fight the vent very much and tolerated the ventilator breaths well.
Problem # 3 : Risk for increase intracranial pressure
General Goal: Maintain an intracranial pressure within normal range

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Predicted Behavioral Outcome Objective (s): The patient will maintain a normal intracranial pressure on the
day of care.

Nursing Interventions Patient Responses

1. Monitor Blood pressure 1. Patients’ blood pressure was

2. Elevate HOB 30 degrees slightly elevated but was
3. Monitor pupil’s reactivity to consistent
light 2. Patient tolerated HOB
4. Administer Keppra to prevent 3. Patients pupils were reactive
seizures to light
4. Patient remained free of
seizures
Evaluation of outcome objectives: Patient tolerated care very well and did not show any signs or symptoms
of increased intra cranial pressure.

Problem # 4 : Ineffective airway clearance

General Goal: Patient will maintain a clear airway

Predicted Behavioral Outcome Objective (s): The patient will always maintain a patent airway at all times on
the day of care.

Nursing Interventions Patient Responses

1. Patient is intubated 1. Patient tolerated endotracheal

2. Monitor SpO2 tube well
3. Auscultate breathe sounds 2. Patient maintained an SpO2
4. Assess ABGs level above 94%
5. Elevate HOB 30 degrees 3. Lung sounds are clear and
6. Suction endotracheal tube as diminished with slight
needed crackles
4. ABGs within normal ranges
5. Patient tolerated HOB
6. Some secretions were cleared
from endotracheal tube

Evaluation of outcome objectives: Patient maintained their airway during the shift and tolerated the
treatments well.

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

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Problem # 5 : Risk for infection

General Goal: No signs and symptoms of infection

Predicted Behavioral Outcome Objective (s): The patient will remain free of signs and symptoms of infection
on the day of care.

Nursing Interventions Patient Responses

1. Monitor temperature 1. Patient had a low-grade fever

2. Assess Vital signs around 100.4 degrees Fahrenheit
3. Monitor IV sights 2. Vital signs within normal ranges
4. Monitor chest tube insertion 3. IV sights were patent and no
sights redness present
5. Hand hygiene 4. Chest tubes free of signs and
symptoms of infection
5. Followed hand hygiene during
shift

Evaluation of outcome objectives: Patient remained free of signs and symptoms of infection.

Problem # 6 : Risk for anxiety and Fear

General Goal: Patient is free of anxiety and fear

Predicted Behavioral Outcome Objective (s): The patient will remain free of fear and anxiety on the day of
care.

Nursing Interventions Patient Responses

1. Keeping the patient informed 1. Patient was kept informed of

on what is happening everything that was
2. Explaining to the patient happening
where they are 2. Patient was explained to
3. Explaining to the patient where they were
what happened 3. Patient was explained to what
4. Provide music to calm the happened that put them in the
patient hospital
4. Played music on the
television to relax the patient

Evaluation of outcome objectives: Patient was able to stay somewhat calm, but the shock of being brought
out of sedation was most likely traumatic for him and caused a lot of anxiety. This being said I was able to
talk to him and set him at ease.

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

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Problem # 7 : Impaired verbal communication

General Goal: Patient will be able to verbally communicate effectively

Predicted Behavioral Outcome Objective (s): The patient will communicate as effectively as he can on the day
of care.

Nursing Interventions Patient Responses

1. Ask only yes or no question 1. Patient was able to

2. Keep patient calm communicate with yes and no
3. Use a communication sheet questions
4. Pay attention to hand motions 2. Patient was able to stay calm
3. Communication sheet was
not available on the floor
4. I was able to decipher what
the patient was trying to
communicate using his hand
motions

Evaluation of outcome objectives: The patient was able to communicate slightly but it was very difficult to
understand him.

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