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Concept Mapping
4832 Nursing Care of Children and Families

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


Key Problem: #1
Risk for infection
Supporting Data:
Wound dehiscence
Elevated WBC’s
Elevated temperature
Isolation
Key Problem #4
Knowledge deficit
Supporting Data:
Disease process
Isolation
Improper wound care of
surgical site
Bathing with cast on
Stepping in animal feces
post operatively
Key Problem
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis
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Key Problem: #2 Key Problem: #3
Risk for impaired skin Impaired mobility
integrity Supporting Data:
Supporting Data: Bilateral surgical leg
Obesity wounds
Bedridden Short leg cast left leg
Non-weight bearing application
Bilateral leg incisions Obesity
History of toe walking
Key Problem #5
Reason For Needing Health Care: Anxiety
Wound dehiscence of open Z lengthening Supporting Data:
bilateral Achilles tendons. Pain
Priority assessment: Surgery
Pain History of anxiety
Skin integrity Cries
Circulation in lower extremities Anxious facial expressions
Bilateral leg wounds Voicing concerns
Patient/ family
Key Problem Key Problem
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Problem # _______:
General Goal: The client will maintain skin integrity as evidenced by no skin breakdown.

Predicted Behavioral Outcome Objective (s): The patient will……

Remain absent of redness and irritation of skin on the day of care.

Nursing Interventions Patient Responses

1. Assist client to turn at

Evaluation least
of outcomes 1. Patient understood prolonged or excessive
objectives:
Outcomes
every two hours unless were met this pressure
shift, on the absent
patient remained skin obstructs
of redness capillary blood
and irritation of skin on the day of care.
contraindicated. flow, thus increasing likelihood for pressure
2. Keep bed linens wrinkle free. wounds
3. Ensure that external devices 2. Patient maintained moderately low
Problem # _______:
such as braces, casts, andGeneral Goal: The amounts of wrinkles
client will on bed
identify ways linens.postoperative infection.
to prevent
restraints are applied properly. 3. Patient maintained casts on both feet
4. Keep bed linens dry. Predicted Behavioral Outcome Objective (s): The patient
properly, and refrained from interacting will……with
Understand andthem.
demonstrate proper wound care to reduce risk of infection on the day of care.
5. Apply a moisturizing lotion
and/or emollient to the skin at 4. Patient maintained dry linens while in bed.
least once a day. 5. Patient aided withPatient
Nursing Interventions application of
Responses
moisturizing lotion to skin.
1. Continue with coughing
4. Maintain good personal 4. Patient understood1.afterPatient understood
teaching after teaching
that good that
coughing and andbreathing
deep deep breathing
help every
to 2
reduce
hygiene. personal hygiene helps to maintain the
hours while awake.
5. Avoid touching any wound integrity of protectiveatelectasis, expandand
mucosal linings, alveoli, and decrease the
2. Increase activity as
unless it is completely healed. reduce the amount of harmful organisms pulmonary infection.
risk of a postoperative
tolerated.
2. Patient maintained a moderate level of
leading toward infections
3.bedrest.
Maintain a balanced
5. Patient understoodactivity while inthat
after teaching
3. Patient nutrition.
Problem # _______: touching a wound may increasenutrition
the was met with dinner
General Goal: The client will improve mobility as evidenced by consisting
increased of chicken
physical nuggets, fruit, and milk.
activity.
transmission of pathogens, increasing the risk
Predicted Behavioral Outcome Objective (s): The patient will……
of infection.
Demonstrate appropriate use of assistive devices to improve mobility on the day of care.

Evaluation of outcomes objectives:

Nursing were
Outcomes Interventions
met this shift, patient was able Patient Responses
to understand and demonstrate proper wound care to reduce
risk of infection during the shift.

1. Encourage and implement 1. Patient understood that inactivity

strength training activities.
Evaluation of outcomes objectives: contributes to muscle weakening, and activity
2. Use assistive devices to
Outcome was met thus shift, patient increases
demonstrated the ability
appropriate to move.
use of assistive devices to improve mobility
during the day of care.
help client with movement. 2. Patient ambulated with walker and
3. Cluster treatments and care successfully transferred from bedside
activities to allow for commode to bed.
uninterrupted periods of rest. 3. Patient was able to rest for longer periods
4. Implement measures to uninterrupted with clustered treatments.
maintain healthy, intact skin. 4. Moisturizers were applied to the patient’s
5. Encourage coughing and skin to retain elasticity and aid with mobility.
deep breathing exercises and 5. Breathing exercises were performed by the
use of incentive spirometry. patient and the importance was understood
and explained.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis