1

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:
Ineffective Airway Clearance/
risk for infection Impaired Gas Exchange Risk for Deficient Fluid
Volume

Reason for Needing Health Care: Key Problem:

Key Problem:
Imbalanced Nutrition: less than
body requirements
Acute Respiratory Failure due to Pneumonia Impaired Verbal
Communication
62 years old, Male, Full Code
Allergies: NKA
Key Assessment: VS with focus on respiratory

Key Problem: Key Problem:

Impaired skin integrity; Impaired Spontaneous

malnutrition and sores Ventilation

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 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.

# Key Problem/ND: # Key Problems/ND: # Key Problem/ND:

Ineffective Airway Clearance/ risk for Impaired Gas Exchange Risk for Deficient Fluid Volume
infection
Supporting Data: Supporting Data:
Supporting Data: FiO2 .60 NPO
Blood tinged secretions Cancer of the Lungs Hypotension 86/69
Zosyn (pipercillin) IV Heavier Smoker Dry pink mucus membranes
Neutrophils 85 (H) Hypoxia with altered mental status Tachycardia
ETT suction every 2 hours Tachycardia
Turn every 2 hours
Diminished breath sounds all lobes

# Key Problem/ND:
# Key Problem/ND:
Imbalanced Nutrition: less than body
Impaired Verbal Communication
requirements
Reason For Needing Health Care
(Medical Dx/ Surgery) Supporting Data:
Supporting Data:
ETT placed in-patient
NPO
Acute Respiratory Failure due to Pneumonia Sedation
Endotracheal tube
Decreased ability to follow verbal
No IV fluids running
62 years old, Male, Full Code commands from nurse
Allergies: NKA
Key Assessment: VS with focus on respiratory

# Key Problem/ND: Data don’t know where to put in # Key Problem/ND:

boxes:
Impaired skin integrity; malnutrition Impaired Spontaneous Ventilation
and sores
Supporting Data:
Supporting Data: On Ventilator
NPO Mode A/C
Fluid imbalances Rate 14
ETT FiO2 60%
Sores on Coccyx TV 470
Abrasion on right hip and right foot PEEP 5
Mouth care every 2 hours

Step 3: Draw lines between related problems. Number boxes as you prioritize problems.

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

 3

LASTLY- label the problem with a nursing diagnosis.

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # _______: Ineffective Airway Clearance and risk for infection
General Goal: Increase airway clearance and no signs or symptoms of infection

Predicted Behavioral Outcome Objective (s): The patient will……have patent airway with breath sounds that are
not diminished and secretions that are not blood tinged and less thick. Will also show no elevation in WBC for
signs of infection on the day of care.

Nursing Interventions Patient Responses

1. Assess breath sounds on all lobes 1. Diminished in all lobes

2. Assess the secretions 2. Blood tinged and thick
3. Give antibiotics 3. Zosyn (pipercillin) IV
4. Suction every 2 hours or PRN 4. Pt coughed when being suctioned
5. Turn every 2 hours 5. Turned with nurse pt also
6. Elevated head of bed coughed when being turned
7. Give breath treatments 6. Elevated in semi fowlers
7. Respiratory came in and gave
treatment

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

 4

Evaluation of outcome objectives: Patent airway with breath sounds clearing, absence of blood tinged secretions
and no signs of infection.

Problem # _______: Impaired Gas Exchange

General Goal: Increase Gas Exchange

Predicted Behavioral Outcome Objective (s): The patient will……have decreased FiO2 and be able to tolerate it
on the day of care.

Nursing Interventions Patient Responses

1. Asses breath sounds 1. Diminished in all lobes

2. Assess ABGs 2. Sent to the lab during our shift
3. Assess the FiO2 3. Decreased for 60% to 40% on the shift
4. Elevate Head of bed 4. Elevated in semi fowlers
5. Assess the chest X-ray 5. Doctor ordered one for the patient
6. Mechanical Ventilation 6. Provides supportive care to maintain
oxygenation and ventilation
Evaluation of outcome objectives: The patient was able to decrease the FiO2 from 60% to 40% during the shift
so the patient was improving.

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 # _______: Risk for Deficient Fluid Volume
General Goal: Increase fluid volume

Predicted Behavioral Outcome Objective (s): The patient will……have increase in blood pressure, moist pink
membranes, heart rate in normal ranges on the day of care.

Nursing Interventions Patient Responses

1. BP 86/69 Temp 97.7 HR 117
1. Assess the vital signs 2. Skin turgor elastic, dry pink mucus
membranes
3. Didn’t vomit on shift
4. Total of 325 mL during my shift
5. Patient sweating
6. BUN was within normal limits

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

 5

2. Assess skin turgor, mucus membranes

3. Assess for vomiting

4. Monitor I & O
5. Monitor for insensible losses
6. Monitor Labs like BUN
Evaluation of outcome objectives: Patient had a heat rate of 96 at end of shift, the skin turgor was elastic but
membranes were still dry and patient was still NPO.

Problem # _______: Imbalanced Nutrition: less than body requirements

General Goal: Improved Nutritional Status

Predicted Behavioral Outcome Objective (s): The patient will……show normal lab values with BUN, will show
no signs of infection, and no abdominal distention on the day of care.

Nursing Interventions Patient Responses

1. Assess the Ng suction 1. Blood tinged

2. Provide oral mouth care 2. Every 2 hours or PRN for the patient
3. Check placement of NG 3. With a CXR everyday and air bolus prn
4. Elevate HOB 4. Patient HOB semi fowlers at all times
5. Monitor labs 5. Normal BUN
6. Assess the stool 6. Patient didn’t have a bowel movement

Evaluation of outcome objectives: Patient had normal BUN levels, no signs of infection, and the abdomen was
nontender soft and symmetric.

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 # _______: Impaired Verbal Communication
General Goal: Effective Communication

Predicted Behavioral Outcome Objective (s):  The patient will…… respond with appropriate non­verbal 
behaviors to verbal commands on the day of care.
Nursing Interventions Patient Responses

8. Neurological Assessment

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

 6

9. Assess ETT tube and cuff 9. Size 7 ½ Lip Line 24

pressure 10. Patient opens eyes to command
10. Assess ability to follow verbal 11. Spoken loud enough so patient
commands could hear and just explained
11. Use soft voice and touch before touching patient
12. Administer sedation 12. Propofol 1.8 mL/hour

8. Patient was sedated

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

 7

Evaluation of outcome objectives: Patient was able to open eyes on command but couldn’t really follow
commands like saying to lift arm up or leg.

Problem # _______: Impaired skin integrity; malnutrition and sores

General Goal: Improved skin integrity

Predicted Behavioral Outcome Objective (s): The patient will…… patient will not have any further skin
breakdown during hospitalization and wounds will be kept clean and free of infection on the day of care.

Nursing Interventions Patient Responses

1. Assess site of impaired skin 1. Sore on coccyx/abrasions on R Hip/R foot

2. Assess odor, drainage, size, color
3. Assess signs for infections
4. Assess temperature
5. Change dressings as needed
6. Change diaper when stool is passed
2. No odor or drainage, sores all were pink
3. Lymphocytes elevated 6
4. Not elevated
5. Normal saline dressing with foam patch
6. Had no BM during shift and had Foley in

Evaluation of outcome objectives: check wounds every shift and change and clean dressing if there is drainage.

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 # _______: Impaired Spontaneous Ventilation
General Goal: Maintain Ventilations

Predicted Behavioral Outcome Objective (s):  The patient will……tolerate ventilator on ordered settings and 
have moist mucous membranes on the day of care.
Nursing Interventions Patient Responses

1. Assess Ventilator Settings 1. Decreased FiO2 during shift .60 to .40

2. Monitor SpO2 2.
3. Mouth Care 3. Did Q2 hours or PRN
4. Watch Sedation 4. 1.8 mL/hour
5. Assess the ETT and cuff pressure 5. Size 7 ½ Lip Line 24

Evaluation of outcome objectives: Patient was able to decrease the FiO2 during shift

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