Concept Map
Client Problem Priority #1: Client Problem Priority #2: Self-care
Impaired Skin Integrity Deficit
Anemia 1. Assisted bed bath
Braden score: 13 2. Repositioning every 2 hours
Purplish blue bruise on right hand 3. Aging
Cues (physical assessment, S & S,
Cues (physical assessment, S & S, lab
Medical Diagnosis lab values, diagnostics, related
values, diagnostics, related
Heart failure meds/treatments):
meds/treatments):
Priority Assessment:
Sympathetic nervous System
Client Problem Priority #3: Impaired
gas Exchange
1. Cough
2. Pneumonia in upper right lobe
3. 3L oxygen
Cues (physical assessment, S & S, List Client Problems: Additional Cues:
lab values, diagnostics, related
Pain, acute Fatigue
meds/treatments):
Impaired, Chest pain
mobility phi Dyspnea
Walking
impaired
Outcomes & Actions/Interventions
1. Identify Client Problem: Impaired Skin Integrity
a. Identify Expected Outcome (generate solutions): Patient will verbalize understanding of daily skin inspection.
b. List 3 Actions/Interventions (1 assessment and 2 interventions). All 3 need to be aimed at the Expected Outcome and
rationale source cited.
i. Take Action/Intervention: Educate the patient on recommended diets to help skin integrity.
1. Rationale:
Diet considerations may depend on each individual with trial and error. A low-residue diet is often prescribed
It may be necessary to limit spicy foods, alcohol, and high-fiber foods which
can cause diarrhea, potentially increasing output and the risk for leakage (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: Click or tap here to enter text. Patient verbalized three ways diet can improve
skin integrity.
ii. Take Action/Intervention: Adjust the patient's position frequently and turn them every two hours.
1. Rationale: Changing the patient's position frequently and turning them every two hours to maintaining
skin integrity (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: the patient was repositioned and turned every 2 hours throughout the shift.
iii. Take Action/Intervention: Continued assessment of skin and bruises.
1. Rationale:
Skin at risk for breakdown should be closely monitored at least once a shift. Observed bruises should be mon
2. Patient Response/Evaluation: Click or tap here to enter text. The patient’s skin was assessed for
breakdowns and bruises.
Evaluate Outcomes: Was the Expected Outcome:
✘ Met
Partially Met
Not Met
c. Why? The expected outcome was met. The Patient verbalized an understanding of daily skin inspection. The Patient
Verbalized 3 ways diet can improve skin integrity.
the patient was repositioned and turned every 2 hours throughout the shift.
Also, the patient’s skin was assessed for breakdowns and bruises.
2. Identify Client Problem: Self-care Deficit
a. Identify Expected Outcome (generate solutions): Patient will assist with a bed bath by the end of the 6 hour shift.
b. List 3 Actions/Interventions (1 assessment and 2 interventions). All 3 need to be aimed at the Expected Outcome and
rationale source cited.
i. Take Action/Intervention: Educate the client and family members about self-care techniques.
1. Rationale: To improve the client’s ability to perform self-care activities,
increase independence, and promote quality of life (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: Click or tap here to enter text. Patient verbalized three ways independence
can improve self image.
ii. Take Action/Intervention: organized/ decluttered the patients table before breakfast.
1. Rationale: To promote independence during meal time (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: The patient ate 75% of breakfast independently with no assistance.
iii. Take Action/Intervention: Encourage client to assist during bed bath.
1. Rationale:
To increase the ability to perform activities of daily living (ADL’s) (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: Click or tap here to enter text. The patient’s assisted with bed bath.
Evaluate Outcomes: Was the Expected Outcome:
✘ Met
Partially Met
Not Met
c. Why? The expected outcome was met. The patient assisted with bed bath, verbalized three ways independence can
improve self image, and independently ate breakfast.
3. Identify Client Problem: Impaired Gas Exchange
a. Identify Expected Outcome (generate solutions): Patient will deny any difficulty breathing by the end of 6-hour shift.
b. List 3 Actions/Interventions (1 assessment and 2 interventions). All 3 need to be aimed at the Expected Outcome and
rationale source cited.
i. Take Action/Intervention: Educate the client and family members about self-care techniques.
1. Rationale: To improve the client’s ability to perform self-care activities,
increase independence, and promote quality of life (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: Click or tap here to enter text. Patient verbalized three ways independence
can improve self image.
ii. Take Action/Intervention: organized/ decluttered the patients table before breakfast.
1. Rationale: To promote independence during meal time (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: The patient ate 75% of breakfast independently with no assistance.
iii. Take Action/Intervention: Encourage client to assist during bed bath.
1. Rationale:
To increase the ability to perform activities of daily living (ADL’s) (Gulanick & Meyers, 2021).
2. Patient Response/Evaluation: Click or tap here to enter text. The patient’s assisted with bed bath.
Evaluate Outcomes: Was the Expected Outcome:
✘ Met
Partially Met
Not Met
c. Why? The expected outcome was met. The patient assisted with bed bath, verbalized three ways independence can
improve self image, and independently ate breakfast.
Reference
Fundamentals For Nursing (11th ed.). Elseveir.Gulanick & Meyers , M. & J. (2021). (10th ed.). Elsevier.
