Professional Documents
Culture Documents
Concept Map
Concept Map
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 Reason for Needing Health Care 2. Risk of clotting r/t A. fib
5. Risk for Impaired Tissue and immobility
Integrity r/t
paralysis/immobility and
anemia
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.
Supporting Data:
Key Problem/ND: Ineffective #3 Key Problem/ND: Anxiety r/t
History of A. fib and HTN
airway clearance mechanical ventilation and
History of smoking and alcoholism
paralysis
Quadriplegic
Supporting Data:
Continuous heparin IV drip
Tracheostomy to vent Supporting Data:
Turn Q2
Diminished breath sounds in all lobes SBP > 150
3+ pitting edema in RUE
Rhonchi auscultated in lower lobes Pain rated 9/10
1+ non-pitting edema in BLE
bilaterally Major surgical complications
10/10 – non-occlusive DVT in R
History of COPD Restlessness in bed
basilic vein
Not breathing above vent; VR and Mouthing “take it off” when
RR both 18 gesturing to tracheostomy tube
Thick yellow sputum requiring Mouthing “I can’t breathe”
suctioning hourly repeatedly
Chest X-ray on 10/12 showed NPO for several days
bilateral pneumonia Reason For Needing Health Care
Fentanyl IV Q4 PRN
(Medical Dx/ Surgery):
Brovana 15mcg BID nebulizer
Pulmicort 500mcg BID nebulizer Quadriplegia following odontoid screw
removal surgery
Xopenex 0.63mg Q6 nebulizer
Anemia due to end-stage renal disease
A. fib, hypertension, COPD, Hepatitis C
66-year old male. DNR-CCA
#4 Key Problem/ND: Impaired Allergies: Levaquin, Penicillins, Tetanus Key Problem/ND: Risk for impaired
renal function toxoids tissue integrity
Predicted Behavioral Outcome Objective (s): The patient will exhibit clear breath sounds and tolerate
trach suctioning every hour on the day of care.
Evaluation of outcome objectives: Outcome partially met. The patient tolerated tracheostomy suctioning
hourly and secretions were cleared. Rhonchi were still auscultated in lower lobes bilaterally, and breath
sounds were diminished in all lobes. Will continue to monitor status.
1. Palpate radial and pedal pulses Q2 1. Radial pulses 3+ and pedal pulses 2+
2. Assess cap refill Q2 2. Cap refill <3 seconds all extremities
3. Assess for new redness or swelling 3. No new redness or swelling observed
4. Heparin IV continuous drip 8.5ml/hr 4. Tolerated well
5. Palpate extremities for warmth Q2 5. No new warm areas observed
6. Perform passive ROM exercises 6. Tolerated well
Evaluation of outcome objectives: Outcome met. No new evidence of clot formation was observed on the
day of care. Capillary refill was <3 seconds and strong pulses were palpable in all extremities.
P.Predicted
Schuster, Concept
Behavioral Mapping:
Outcome A Critical
Objective(s): Thinking
Patient Approach,
will exhibit Davis, 2002.
calm behaviors and report pain level <5/10
on the day of care.
4
Evaluation of outcome objectives: Outcome not met. Patient still restless and agitated in bed. Repeatedly
mouthing “I can’t breathe” and asking to be taken off the vent. Reports pain level 7/10, even with
medication. Will continue to monitor.
Predicted Behavioral Outcome Objective(s): Patient will exhibit no new pressure ulcers on the day of care.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
Evaluation of outcome objectives: Outcome met. Patient developed no new pressure injuries on the day of
care. Will continue to turn Q2, elevate heels, and assess high pressure areas frequently.
Predicted Behavioral Outcome Objective(s): Patient will demonstrate understanding of rationale regarding
care by responding appropriately to yes or no questions.
Evaluation of outcome objectives: Outcome not met. Patient not cooperating with questions. Restless
movements and refusing vent despite explanation of the necessity of it. Will continue to find better ways
to communicate and allow patient to express his needs.