1

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 #2 Key Problems/ND #3 Key Problem/ND

Impaired gas exchange Risk for decreased tissue Deficient Fluid Volume
 SOB perfusion  hypotension
 4L NC  Fluid loss from surgery  Recent fluid loss
 CAD  Hx of CAD, DM2 from Open Heart
 DM 2  Hypotension  2L of NS
 Diminished lung sounds  Arterial line  500ml of Albumin
 Pressors  pressors
 2.5L of fluids bolused

# Key Problem/ND:
#4 Key Problem/ND
Risk for blood clots
 Pneumatic
Reason For Needing Health Care Compression device
in use
NSTEMI + CABG x 3  “Blood Thinners,”
like Plavix and
Aspirin
 Patient immobile for
long stretch of time
 Post-Op patient

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

Risk for Infection Risk for bleeding
 Open Heart Surgery  “Blood Thinners”
 Prophylactic antibiotics  CABG x 3
 Indwelling Catheter  4 Chest tubes
 Incisions on legs for
veins

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

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

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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: Patient’s 02 Sat will remain above 90%

Predicted Behavioral Outcome Objective (s): The patient will not feel SOB or show any signs of respiratory
distress.

on the day of care.

Nursing Interventions Patient Responses

1. 4L of 02 on NC 1. Pt SAT remained above 90%

2. Continuous O2 monitoring 2. Pt showed good oxygenation.
3. High fowlers positioning 3. Patient’s breathing improved.
4. Swallow test post extubation 4. Airway protected.
5. Patient taught how to cough. 5. Pt able to remove secretions.
6. ABG 6. PaO2 125.4 at 15:10
7. 7.
8. 8.

Evaluation of outcome objectives: Patient’s breathing was symmetrical and unlabored with a normal RR.
Outcome Met

Problem # 2: Risk for decreased tissue perfusion

General Goal: MAP > 65 and Capillary refill < 3 seconds
Predicted Behavioral Outcome Objective (s): The patient will respond and tolerate interventions well

on the day of care.

Nursing Interventions Patient Responses

1. Give bolus as needed 1. Patients’ blood pressure went up.

2. Titrate Vasopressin drip 2. MAP remained > 65
3. Blood thinners provided 3. No S&S of blood clots
4. Catheter and chest tubes 4. Able to accurately I&O’s
5. Monitor cap refill 5. < 3 sec in all extremities
6. Administer Tamsulosin 6. Helped afterload on the Heart
7. 7.
8. 8.
Evaluation of outcome objectives: Capillary refill remained less than three seconds, BP stabilized along with
MAP (which was greater than 65). Able to start weaning patient off vasopressin. Outcome Met

Problem #3: Deficient fluid volume r/t intra operative procedure

General Goal: Patient’s blood pressure will stabilize SBP >90

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Predicted Behavioral Outcome Objective (s): The patient will remain calm and cooperative

on the day of care.

Nursing Interventions Patient Responses

9. 2.5L worth of fluids bolused 9. Patients BP went up.

10. Taught to brace when coughing. 10. Minimized BP drops
11. 25g of Albumin 11. Help keep fluid in right place
12. Vasopressin 0.04u/min 12. Helped stabilize BP
13. Monitor chest tubes 13. No excessive blood loss
14. Administer Tamsulosin 14. Helped afterload on heart
15. 15.
16. 16.

Evaluation of outcome objectives: Patients blood pressure rose above 110 SBP and we were able to titrate off
Vasopressin. No excessive blood loss through chest tubes. Outcome Met.

Problem # 4: Risk for blood clots

General Goal: No S&S of blood clots
Predicted Behavioral Outcome Objective (s): The patient will be calm and cooperative

on the day of care.

Nursing Interventions Patient Responses

1. Pneumatic compression device 1. No S&S of blood clot in right leg

2. Administer 75mg Clopidogrel 2.No Adverse reactions
3. Education on incentive spirometer 3. Patient was cooperative
4. Administer baby Aspirin 4. No adverse reactions
5. Check pulses in lower extremities 5. Pedal Pulse +1 BL
6. ACE wrap on left leg 6. Compressed to help blood flow
7. 7.
8. 8.
Evaluation of outcome objectives: Patient showed no signs or symptoms of a thrombus. Outcome Met.

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 # 5: Risk for Bleeding
General Goal: No excessive Blood loss

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

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Predicted Behavioral Outcome Objective (s): The patient will remain calm and cooperative

on the day of care.

Nursing Interventions Patient Responses

17. Monitor for S&S of bleeding. 17. No S&S of abnormal bleeding

18. Check dressings. 18. Dressings Dry and Intact
19. Monitor chest tubes 19. No excessive blood loss
20. Educate patient on safety 20. Unable to educate pt d/t sedatives
21. Patient restrained for safety 21. Pt didn’t fight the restraints
22. Monitor BP and HR 22. HR stable (60-100), low BP
23. 23.
24. 24.

Evaluation of outcome objectives: Patient had a normal amount of drainage from the chest tubes. No signs of
bleeding anywhere else. Outcome Met

Problem # 6: Risk for infection

General Goal: No S&S of infection.
Predicted Behavioral Outcome Objective (s): The patient will remain calm and cooperative

on the day of care.

Nursing Interventions Patient Responses

1. Interval temperature checks 1. Highest temp 99.9

2. check drainage on chest tubes. 2. No abnormal appearance
3. Check temperature around sites 3. Consistent with body temperature
4. Administer prophylactic Antibiotics 4. No Adverse side effects.
5. Check incision sites 5. Unable to assess.
6. Monitor Labs 6. Last WBC 7.5
7. 7.
8. 8.
Evaluation of outcome objectives: Some surgical sites we were UTA, no abnormal drainage or wounds on
what we could see. Outcome partially met.

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