Carlie Deidrick

Concept Map

Ineffective Breathing Pattern
r/t sleep apnea and edema
Mother reports patient having
periods of apnea during sleep
and snoring episodes.
1 BP 126/86
SpO2 95% post-op
Risk for Deficient Fluid
Volume r/t inadequate
fluid intake
Child does not want to
drink fluids.
7 oximetry especially when sleeping,
Disturbed Sleep
Pattern r/t
environmental
changes and pain.
Restlessness
Fatigue 3
Acute pain r/t surgical
incisions and edema
Patient rates pain at 4/10
on FACES scale.
Restlessness
2 child at home.
Reason for Needing Health Care
Obstructive Sleep Apnea leading to
tonsillectomy and adenoidectomy
Key Assessments: respiratory rate &
effort, lung sounds, continuous pulse
post-operative vital signs, surgical
wound assessment.
Risk for Imbalanced
Nutrition: less than body
requirements r/t nausea
and pain
8
Child reports nausea.
Child is afraid to eat
because her throat hurts.
Deficient Knowledge
(Postoperative Home Care) r/t
lack of exposure to
information regarding
tonsillectomy ad
adenoidectomy
Mother states lack of
understanding for caring for
Mother asked about diet post-
op and at home.
Mother had questions about
normal reactions to surgery.
5
Anxiety r/t change in
health status and change in
environment.
BP 126/85
Child is clinging to
mother.
Mother is restless and
questions all care.
Never leaves bedside. 4
Risk for Infection r/t
surgical wound
Open incision 6
Assess site and
temperature often.
Problem #1 : Ineffective Breathing Pattern
General Goal: Patient will be able to breathe easier.
Predicted Behavioral Outcome Objective (s):
The patient’s SpO2 will remain above 95% until the end of shift.

Interventions Rationales
1. Assess frequency and pattern of Children with apnea have periods of breathing cessation
breathing. for 15-20 seconds.

2. Assess skin, nail beds, and mucus Reveals presence of hypoxemia from uneven
membranes for pallor/cyanosis. distribution of gas and blood in the lungs.

3. Place child on a continuous pulse Post-operative protocol and it monitors changes in

oximeter. respiratory system.

4. Assess for changes in consciousness Reveals state of hypoxia as level of oxygen decreases.
or irritability.

5. Discourage intake of dairy products. May coat the throat causing child co cough and clear
throat, causing discomfort.

6. Encourage fluid intake. Hydration helps to loosen secretions.

7. Have suctioning equipment available To remove clots at surgical site in event of airway
at the bedside. obstruction.

8. Teach and demonstrate breathing Promotes lunge expansion, gas exchange, and decreases
exercises. pneumonia risk.

Evaluation of outcomes objectives:

Met. Patient’s SpO2 remained above 95% during shift.

Problem #2 : Acute Pain
General Goal: Provide pain management
Predicted Behavioral Outcome Objective (s):
The patient will describe pain level <3 by the end of shift.

Interventions Rationales
1. Assess pain with an appropriate pain A pain scale provides an objective measure of subjective
scale. data.

2. Assess pain characteristics Assessing is the 1st step to providing pain managements
strategies.

3. Assess for signs and symptoms Children may deny pain to continue playing.
relating to pain

4. Provide distraction techniques. TV and play can take children’s minds off low levels of
pain.

5. Administer pain medication to control Medicating before pain becomes severe can lead to
post-operative pain. better patient outcomes.

6. Apply ice to the area in pain. To reduce edema and pain from pressure on the incision.

7. Reassess pain every 4 hours. Reassessing tells us if pain management strategies are
helpful.

8. Foresee the need for pain relief. Preventing pain and early intervention can decreased the
amount of pharmacological relief needed.

Evaluation of outcomes objectives:

Met. Patient rated pain a 0/10 on the FACES scale at the end of shift.
Problem #3 : Disturbed Sleep Pattern
General Goal: Patient will sleep without difficulty and appear rested.
Predicted Behavioral Outcome Objective (s):
The patient will sleep for 6 hours without interruption during day shift.

Interventions Rationales
1. Assess sleep patterns and changes in Provides baseline for sleep needs related to age
sleep pattern. requirements.

2. Assess for restlessness, pain, Possible reasons for restlessness and sleep deficit.
temperature, and dyspnea.

3. Avoid waking or interrupting sleep Provides comfort without interruption.

for care.

4. Follow home routines for bedtime. Promotes comfort and familiarity.

5. Allow time for quiet play before bed. Avoids overstimulation before sleeping.

6. Provide quiet, calm, and warm Promotes rest periods.

environment.

7. Encourage parent to stay with the Promotes sleep and relaxation by having a familiar
child at night. caregiver.

8. Avoid painful or invasive procedures Decreased stimuli that prevent rest and sleep.
at bedtime.

Evaluation of outcomes objectives:

Not met. Patient was attempting to fall asleep at end of shift.

Problem #4 : Anxiety
General Goal: Reduce anxiety expressed by child and family.
Predicted Behavioral Outcome Objective (s):
Child and family will express decreased anxiety on the day of care.

Rationales Rationales
1. Assess child and parent’s level of Provides a baseline for care.
anxiety.

2. Allow expression of feelings and Provides opportunity to vent feelings and fears to reduce
concerns about procedures. anxiety.

3. Provide a calm, relaxing, and Assists in reducing stimuli to reduce anxiety.

accepting environment.

4. Avoid rushing through interactions Assists in obtaining emotional stability and promotes
and care. trust.

5. Provide orientation to hospital Familiarities promote a secure feeling and reduces fear
environment and routine. of the unknown.

6. Encourage child and family Promotes participation in hospitalization.

involvement in planning care.

7. Approach child in a positive way and Promotes trust and rapport.

avoid judgement.

8. Inform child and family that anxiety Prevents feelings of inadequacy and embarrassment.
and fear is normal.

Evaluation of outcomes objectives:

Met. Child no longer clings to family and family is relaxed.

Problem #5 : Deficient Knowledge (Postoperative Home Care)
General Goal: Parents will gain knowledge to care for post-op child safely at home.
Predicted Behavioral Outcome Objective (s):
Parents will demonstrate knowledge of diet and post-op safety on day of care.

Interventions Rationales
1. Assess parent’s knowledge of Provides baseline for understanding.
condition and management.

2. Allow time for teaching. Allows time for adequate learning and questions.

3. Use a variety of methods to spread Guarantees that any type of parent receives adequate
knowledge. teaching.

4. Teach parents about risks during Provides information to recognize and prevent
post-operative period. complications.

5. Instruct parents to refrain child from Provides information to prevent complications.

strenuous activity.

6. Instruct parents to encourage clear Provides information to avoid dehydration and other
liquids and soft foods. complications.

7. Teach parents how to evaluate for Prevents dehydration complications.

dehydration.

8. Provide medication teaching for at Prevents medication complications.

home medications. Do not take aspirin
and finish the full steroid regimen.

Evaluation of outcomes objectives:

Met. Parent stated that child could have clear liquids and soft foods and progress
slowly to a more general diet.
Problem #6 : Risk for infection
General Goal: Child will not experience infection symptoms.
Predicted Behavioral Outcome Objective (s):
Patient’s temperature will remain under 101 degrees F during shift.

Interventions Rationales
1. Assess temperature every 4 hours. Temperature above 101 may indicate infection
development.

2. Monitor lab work. Increased WBC count could indicate infection

development.

3. Wash hands before and after care. Prevents spread of microorganisms that cause infection.

4. Assess site for drainage and bleeding. Indicates infectious process at the site of the wound.

5. Maintain sterile technique for IV site Prevents contamination.

changes and skin breaks.

6. Change IV site and tubing according Prevents bacterial growth and prolonged vein irritation.
to protocol. (Usually 72 hours)

7. Teach parents to take oral and Monitors for infection while at home.
axillary temperatures.

8. Instruct patient and family on caring Maintains cleanliness and prevents infection.
for site.

Evaluation of outcomes objectives:

Met. Child’s temperature remained in the normal range with no infection indication.
Problem #7 : Risk for Deficient Fluid Volume
General Goal: Promote fluid intake and prevent dehydration.
Predicted Behavioral Outcome Objective (s):
Patient will have an intake of 350 mL during shift.

Interventions Rationales
1. Measure and record Intake & Output Provides information about fluid balance.
hourly.

2. Monitor responsiveness, pulse, blood Restlessness, tachycardia, and tachypnea are early signs
pressure, and respiratory rate. of hypovolemia.

3. Monitor for signs of post-operative Provides information on site integrity and fluid loss.
bleeding.

4. Administer IV fluids as ordered and Replaces losses from surgery and maintains hydration.
monitor hourly.

5. Provide clear fluids in small amounts. Small quantities may be more easily tolerated.

6. Discourage use of straws or any Lessens risk for physical trauma to operative site.
mouth objects.

7. Utilize creative techniques to make Swallowing may be uncomfortable so encouragement to

drinking fluids a game. drink will be needed.

8. Use nonpharmacological ways to Vomiting will decrease fluid volume and increase
prevent nausea and vomiting. bleeding risk.

Evaluation of outcomes objectives:

Met. Patient drank 200mL and IV ran at 78mL/hr for 3 hours pf shift until
discontinued.
Problem #8 : Risk for Imbalance Nutrition: Less than body requirements
General Goal: Patient will experience balanced nutrition
Predicted Behavioral Outcome Objective (s):
Patient will eat 75% of her dinner on the day of care.

Interventions Rationales
1. Assess history of food intake. Provides baseline for nutritional pattern and habits.

2. Assess appetite changes. Indicates health status and effects of surgery.

3. Assess height and weight and Provides information on child’s nutritional status.
compare to growth charts.

4. Assess difficulty and pain with Provides information about child’s nutritional status.
swallowing.

5. Assess presence of nausea or Information about emesis which effects nutrition intake.
vomiting.

6. Offer age appropriate foods that are Promotes ingestion and retention of food.
not irritating to the throat or GI tract.

7. Request parents to bring in food from Promotes appetite with familiar types of foods.
home if desired.

8. Offer food in small quantities near Prevents irritation and promotes a familiar schedule.
usual routine.

Evaluation of outcomes objectives:

Met. Patient are 100% of her dinner.