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 secking 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 Decreased Airway Risk for Infection Risk for skin breakdown Key Problem Key Problem ‘Reason for Needing Health Care Nutritional Deficit Intracranial Bleeding Key Problem Key Problem Key Problem Pain management Knowledge deficit P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.Step 3: DRWINNESIBERVEENICISIEMPFOBIONS. 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: Decreased airways General Goal: Improve oxygenation and ventilation status Predicted Behavioral Outcome Obj ventilation on the day of care. (3): The patient will maintain an SPO2 above 95% on A/C mode N 1. Reposition client as needed 1. Q2 tums with pillows 2. Elevate H.O.B 2. Patient SPO2 was 95% or higher 3. Suction patients’ mouth 3. Decreased saliva blockage in mouth 4. Provide breathing treatments 4. Lungs clearer on auscultation 5. Assess lung sounds 5. Lang sounds wee cle iaterally 6. Adjust vent settings as needed Sn ence 7. Monitor SPO2/ABG levels Prana eee 4. Patient sedated to preserve 02 8. Patient had a RASS score of -1 Evaluation of outcome objectives: Patients SPO? levels never fell below 95% during my shift. Goal was met. Problem #2: Risk for Infection General Goal: Prevent the patient from developing infections such as ventilator associated pneumonia Predicted Behavioral Outcome Objective (5): The patient will not have an increase in White Blood Cell count for temperature on the day of care. ‘Nursing interventions Patient Responses 1. Patient was bathed 1. Improved patients’ mood/comfortability 2. Gowns/lines were changed 2. Patient was dirty due to urination 3. Oral care was performed 3. Patients mouth was cleaned of bacteria 4, Antibiotics were administered 4. Patient tolerated antibiotic therapy 5. Suetioning was performed 5. Coughed/gagged 6. Skin care was performed 6. Skin was red but no wound formation 7. WBC count was monitored 7. WBC count was at 8.2 8. Vital signs were monitored 8. Vitals were within normal range Evaluation of outcome obje ‘was met.Problem # 3: Risk for skin breakdown General Goal: Patient will not develop any open wounds white lying in bed Predicted Behavioral Outcome Objective (3): The patient will be turned every two hours to prevent any new ‘wounds from forming on her sacral area on the day of care. ‘Nursing Interventions Patient Responses 1. Q2 tums 1, Patient preferred pillows over wedges 2. Assessed skin Q2 hours 2. Skin was red but not open 3. Applied Vaseline to reddened areas -—_3, Prevented skin from breaking down 4, Kept patient cleaned 4. Cleaned twice due to incontinence $. four eyes check on patient 5. Skin was red but not opened 6, Heel protectors applied 6. Kept kicking protectors off 7. Heels elevated off bed 7. No redness was present on heels 8. Maintained proper nutrition on tube feed 8, Patients weight remained stable at 115kg Evaluation of outcome objectives: No new wounds developed while on my shift. Goal was met, Problem # 4: Improper pain management General Goal: Keep the patient comfortable while on the ventilator Predicted Behavioral Outcome Objective (3): The patient will not fight against the ventilator on the day of care, “Nursing Interventions Patient Responses 1. Repositioned client 1. SPO2 levels were at 95% or higher 2. Monitored pain using CPOT scale 2. CPOT score was 3 3. Kept patient sedated 3. RASS score was -1 4. Offered pain medication PRN 4. Dilaudid was given for CPOT of 3 5. Performed oral care/mouth swabs ‘5, Mouth was cleaned and moisturized 6. Suctioned patient 6. Patient coughed/gagged 7. Loosened restraints 7. Patient was on light sedation (RASS -1) 8. Q2 tums 8. Patient preferred pillows over wedges Evaluation of outcome objectives: Patient fully complied with the ventilator and did not try to fight against it. Goal was met, P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.Problem # $: Nutritional deficit General Goal: Patient will maintain adequate nutrition while staying in the hospital Predicted Behavioral Outcome Objective (s): The patient will maintain her weight and not have severe weight loss (oss of 1-21bs daily) on the day of care. Nursing Interventions Patient Responses 1. Monitor weight daily 1, Weight remained stable 115kg 2. Monitor /0’s 2. Feed ran at 30mL/h, 2 bowel movements, SOOmL output 3. Monitor tube feed rate 3. Tube feed ran at 30mL/hr 4, Assed tube feed for complications 4. No complications were present 5. Assess GI (sounds, inspection etc) 5. Stomach obese/ sounds were hypoactive 6. Blood sugar checks 6. BS= 111 7. Consult dietary 7. Dietary provided tube feed as needed 8. Monitor electrolyte levels, 8. K, Ph, C, total protein= low. Cl=high Evaluation of outcome objectives: Patients weight stayed around 115kg from the day of admission through my day of care. Goal was met. Problem # 6: Knowledge deficit General Goal: Educate patient about condition as well as health maintenance/prevention Predicted Behavioral Outcome Objective s): The patient will have a better understanding of their health condition on the day of care Nursing Interventions Patient Responses 1. Educate on mechanical ventilation 1. No evidence of education, needs reinforcement 2. Educate on nutrition 2. No evidence of education, needs reinforcement 3, Educate on skin care 3. No evidence of education, needs reinforcement 4, Educate on infection prevention _4, No evidence of education, needs reinforcement 5, Educate on medication adherence 5. No evidence of education, needs reinforcement 6. Educate on patients’ condition 6. No evidence of education, needs reinforcement 7. Educate on why they're on restraints 7. No evidence of education, needs reinforcement 8. Educate on fall risk prevention 8. No evidence of education, needs reinforcement Evaluation of outcome objectives: Patient was unable to verbalize or show any understanding of the health teachings that were provided. Goal was not met. P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.‘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 bealth care (chief medical disgnosis/surgical procedure) and put | {2 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. AIC mode (Risk for developing V.A.P) © Immobile Fighting the ventilator Hydromorphone ordered Patient repositioned Educate on importance of the ventilator * Educate on procedures) interventions that are being done P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.