NURSING 102 THERAPEUTIC COMMUNICATION
CONCEPT MAP
Please read the following case study and fill out the concept map below. Fill in Objective & Subjective
data. Develop two Nursing Diagnoses (NANDA approved). DIAGNOSIS HAS TO BE PRIORITIZED.
Establish appropriate Nursing Interventions- FOUR INTERVENTIONS FOR EACH PROBLEM (NIC
approved). Please fill in the evaluation section by describing what you think would happen in this
scenario based on your diagnoses and interventions.
Mr. Lawson is a 62 year old patient who had abdominal surgery for a colon resection and removal of a
tumor two days ago. His nurse, Tonya, implemented pain-control strategies in an effort to help him
become more mobile to aide in the recovery process. Until now, he was getting out of bed and rating
his pain at a level of 5 on a scale of 0 to 10. The patient tends to guard his incision by placing his hand
over the wound when moving.
Mr. Lawson weighs 220 lbs and is 5 ft 11 inches tall. He has tried to cough more during his
postoperative deep-breathing exercises. Tonya is caring for him for the third day in a row and begins
the morning shift by inspecting his surgical wound. The wound is approximately 15 cm in length and
closed with steel sutures. Tonya notices separation of the wound between two sutures at the bottom
of the incision. There is a small amount of serous drainage. The area is inflamed and she asks the
patient if the incision is tender when she gently palpates around the area. Mr. Lawson states, “Ow,
that feels sore there. I think I pulled it when I coughed last night.” He rates his pain at this time as
being at a level of 5.
Tonya checks Mr. Lawson’s vital signs and notes that his temperature of 38.2 C. Tonya also inspects
the intravenous access device in the patient/s left forearm. It is intact, and there are no signs of
phlebitis at the IV site. Mr. Lawson states that he will have activity restrictions and his wife will be of
assistance to him once he returns home. His discharge has been planned tentatively. His family
depends on his income he appears anxious when sharing concerns with Tonya about being able to
return to work after surgery. He consistently does not seem to understand Tonya when she is
teaching reviewing discharge plan & teaching discharge instructions. Mr. Lawson also verbalized
some concern by asking Tonya, “The doctor told me that I would not be able to lift anything heavy
and I’m not so sure if I understand. The way my incision looks, will I need to do something to it?”
KD 6-19
CONCEPT MAP
SUBJECTIVE DATA:
 Pain
OBJECTIVE DATA:
 Pain score - 5
 Guarding the incision
 separation of wound
 inflamed wound site
 Palpate tenderness
 small amount of serous
drainage
 temperature of 38.2 C
NURSING
DIAGNOSIS/PROBLE
M PRIORITY 1:
Acute Pain ( in
abdomen) related to
surgical incision, as
evidenced by
verbalization, pain
score, guarding
behavior,
inflammation,
tenderness during
palpation
EVALUATION:



Patient will verbalize decreased
level of pain (lower pain score)
No guarding of the incision side
Normal body temperature
SUBJECTIVE DATA:
 Expresses concern
 Anxious
OBJECTIVE DATA:
 Lack of attention/focus
 Reduced understanding
with confusion
KD 6-19
INTERVENTIONS:
 Assess the level of pain
 Administer analgesics
as per order
 Provide change of
dressing aseptically
 Encourage use of
relaxation techniques
 Provide comfort
measures ex: back rub,
repositioning
EVALUATION:




Reduced Anxiety
Improved patient participation
Improved coping mechanism
Patient able to teach back and
explain discharge plan and
discharge instructions
NURSING
DIAGNOSIS/PROBLEM
PRIORITY 2:
Deficient Knowledge
related to procedure as
evidenced by verbalizing
inability to understand
INTERVENTIONS:
 Assess the level of
knowledge
 Health educate
about disease
condition
 Clarify any
questions

 Encourage patient
to take part in the
care
 Teach patient
problem solving
techniques