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Colton Graham’s Concept Map

4832 Nursing Care of Children and Families

Key Problem #1/ ND: Key Problem #2 ND:

Impaired Gas Exchange Ineffective airway
Supporting Data: clearance (increased Key Problem #3 ND:
HOB elevated secretions) Hyper/Hypothermia
O2 saturation 89 Supporting Data: Supporting Data
Concept
HR 132 Mapping- Colton Graham O2 saturation 89 Temp- 101.3
RR- 46 Nasal Suctioning PRN and Warm/ Moist Skin.
Retractions- subcostal and w/ feedings Blotchy skin
Intercostal Fatigue w/ feeding Irritated/ restless
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Key Problem #5 ND: Risk

Key Problem #4 ND: Reason for Needing Health Care
Activity Intolerance RSV
Supporting Data: Key Assessment
Rest periods between Lung Sounds
activities Respiratory Rate / Heart rate
Retractions present Capillary refill
Lethargic/ fatigued easily Fluid and electrolyte balance
Feeding causes fatigue I & O monitoring
Flushed skin Pulse Ox
Skin color/ turgor/ integrity
for Dehydration/ Fluid and
Electrolyte imbalance
Supporting Data:
Dry mucous membranes
Skin turgor
Sunken fontanel
UA- high specific gravity
Capillary refill >2 sec
Weight loss (minimal 5%)

Key Problem #6 ND: Key Problem #8 ND:

Parental Anxiety/ Fears
Supporting Data:
Restlessness/ Increasing
irritability
Repetitive questioning of
status and care given
Frequently asks for Doc
Anxious/ worried facial
expressions
Need for constant
reassurance
Express concerns even over
and over again
Will not leave bedside
Key Problem #7 ND: Care
Giver Role Strain
Supporting Data:
2- older siblings at home
Father works out of town
No Family support r/t
living in different states
Exhaustion- r/t traveling
from hospital to home.
Discharge/ Transitioning
care to home
Supporting Data:
Fear condition will return/
worsen at home
Constant Reassurance that
child can be discharged
Lack of education on
illness or disease process

Concept Mapping- Colton Graham

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Problem # 1:
General Goal: Increase gas exchange/ oxygenation

Predicted Behavioral Outcome Objective (s): The patient will…… Maintain SPO2 reading >93
throughout shift with no oxygen supplementation.

on the day of care.

Nursing Interventions Patient Responses

1. Suctioning PRN and w/ feedings 1. Improved breathing pattern and decreased RR

2. Continuous pulse Ox reading 2. Understood significance of continuous monitoring
3. Prioritize care (feeding first thing) 3. Improved nutritional intake
4. Rest periods to minimize fatigue 4. Rest periods allowed for regained strength and ability to
complete activities

5. Elevate HOB to 45% 5. Decrease respiratory stress & regular respirations

6. Education on positioning for feeding
and holding the baby 6. Demonstrated proper positioning techniques
7. Educate on signs of hypoxia 7. Listed signs of hypoxia and significance of findings

Evaluation of outcomes objectives:

Patient was able to have oxygen saturation above 93% with supplemental oxygen used briefly during feedings

Problem # 2:
General Goal: Improve breathing patterns and decrease respiratory stress by maintaining
patent airway
Predicted Behavioral Outcome Objective (s): The patient will…… have a patent airway with
decreased nasal congestion, clearer breath sounds and show no signs of hypoxia

on the day of care.

Nursing Interventions Patient Responses

1. Deep Nasal suctioning when PRN 1. Mother learned proper suctioning technique, cloudy
Secretions removed, and dyspnea did not occur with feeding

2. Monitoring I and 0 2. Mother saved diapers when infant was changed for weights
3. HOB elevated 30-45% 3. Patient showed less signs and symptoms of hypoxia
4. Education on fluid intake 4. Understands that hydration thins secretions and helps with
Eliminating congestion

Evaluation of outcomes objectives:

Patients Respiratory rate pattern was regular, retractions were less visible, and patient’s airway sounded less
congested.

Concept Mapping- Colton Graham

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Problem # 3:
General Goal: Patients temperature is regulated within normal range (97-99 degrees)

Predicted
Predicted Behavioral
Behavioral Outcome
Outcome Objective
Objective (s):
(s): The
The patient
patient will……
will……
Maintain
Maintain temperature
temperature between
between 97
97-and
and99 degrees Fahrenheit
99-degrees Fahrenheitthroughout
throughoutshift
shift
on
on the
the day
day of
of care.
care.
Nursing Interventions Patient Responses

1. Meds- Tylenol every 4-6 hrs
2. Hourly Temp recordings
3. Monitor I and O
4. Maintenance fluid requirements
5. Education on proper clothing
6. low lighting/ decrease stimulation
1. Parents understood importance of Tylenol compliance
2. Understood importance of continuous monitoring
3. Education on risks for dehydration due to increase use of
Water with higher temperatures.
4. Importance of keeping balanced fluid and electrolytes
5. Proper dressing can prevent increases in temperature and
Swaddling in heavy blankets should be prevented
6. Parents understand that stimulation can lead to increases in
temperatures

Evaluation of outcomes objectives:

Patients temperature was able to stay in the 97-99 range degree with the use of Tylenol and proper fluid intake
throughout the shift

Problem # 4:
General Goal: Improve activity tolerance and patient will show no signs of fatigue during
day of care
Predicted Behavioral Outcome Objective (s): The patient will…… perform activities throughout
the day without showing signs of fatigue.

on the day of care.

Nursing Interventions Patient Responses

1. Decrease stimulation during rest
2. Supplemental Oxygen as needed
3. Clustering of patient care
4. Feeding as soon as patient wakes up 4. Feeding first allows for better nutritional intake and energy
5. Monitor I & O
6. Develop routine that can be followed
At home
1. Parents understand that less interruptions during rest allows
for better quality rest and improved energy.
2. Decreasing the energy required for breathing allowed the
Patient to have more energy to complete other activities
3. Clustering allowed the patients to complete multiple
Activities in a shorter time
5. Parents understand that I & O is needed to provide the
nutrition needed gaining strength
6. A routine that can be followed at home is important for
preventing the reoccurrence of the issue.

Evaluation of outcomes objectives:

The infant was able to complete activities without signs of fatigue due to proper clustering of activities and
rest periods.

Concept Mapping- Colton Graham

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Problem #5:
General Goal: Rehydrate patient and maintain fluid balance

Predicted Behavioral Outcome Objective (s): The patient will…… obtain normal vital signs
(BP, HR, RR), capillary refill will be less than 2 seconds, and mucous membranes will be moist.

on the day of care.

Nursing Interventions Patient Responses

1. Calculate maintenance fluids

Needed for the patient. 1.Parent understand that fluid requirements change
Based off of infant’s weight
2. Monitor vital signs Q 4 hrs 2. Parents were relieved to see positive changes in
Vitals, infant was irritated with Bp monitoring
3. Monitor I and O 3. Parents understood importance of weighing diaper
4. Education on proper fluid
Intake 4. Parents understood importance of reaching
Fluid requirements and how to monitor intake
5. Education on signs and
Symptoms of dehydration 5. Parents could repeat signs of dehydration
6. IV therapy/ fluid replacement 6. Infants vitals started to normalize and positive
Signs of dehydration diminished.
Evaluation of outcomes objectives: The patients vital signs fell within normal limits and assessment findings
of dehydration were diminished.

Problem # 6:
General Goal: Reduce any anxiety parents may experience

Predicted Behavioral Outcome Objective (s): The patient will…… The parent will understand
full diagnosis and plan of care, which will help decrease parent’s anxiety by the end of the shift.

on the day of care.

Nursing Interventions Patient Responses

1. Educated parents on disease process 1. Parents fully understood diagnosis of their infant
2. Involved parents in infants care
3. Educated parents on updated labs
And test results
4. Listened to parents expresses their
concerns and ask questions
5. Encouraged parents to leave bedside
So, they could take time for themselves.
2. Parents could assist in care eliminating stress
3. Keeping them up to date seemed to relieve stress
4. Hearing their concerns and answering their questions
put them at ease.
5. Parents were able to leave bedside and perform selfcare
And this help relieve stress.

Concept Mapping- Colton Graham

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6. Educated parents on plan of care for

The infant 6. By educating them on what to expect in the future it helped
Alleviate stress that comes from not knowing.

Evaluation of outcomes objectives: The parents were able to verbalize that they were less stressed after all of
their question were addressed, and they were able to perform self-care during my shift.

Problem # 7_:
General Goal: Reduce stressors for the caregiver and prevent role strain

Predicted Behavioral Outcome Objective (s): The patient will…… identify stressors and explain
at least one method of decreasing the stressor within reason on the day of care.

on the day of care.

Nursing Interventions Patient Responses

1. Ask caregiver current methods

of reducing stress
2. Offer to care for child so caregiver
can rest
3. Provide positive ways to deal w/stress 3. Parents could express new and positive ways to decrease
4. Offer to discuss stressors w/ parent
5. Encourage parents to take care of
their health too
6. Offer access to resources outside of
hospital resources.
1The parents were able to share what works best for them
2. Verbalized how nice it was to step away for a little bit
Stress.
4. Parents were open about what was bothering them and it
Helped establish trust with the caregiver
5. Parents were able to put themselves first for the first time
since being admitted to the hospital
6. Offering resources such as counseling, support groups etc…
helps them realize they have support from others.

Evaluation of outcomes objectives: The caregivers were able to identify their different stressors and name one
positive method for dealing with the stressor.

Problem # 8:
General Goal: Transition care from hospital to home after discharge

Predicted Behavioral Outcome Objective (s): The patient will……be able to reiterate how to
care for the patient upon returning home
on the day of care.

Nursing Interventions Patient Responses

1. Ensure full understanding of disease

process 1. Parents understand how disease process works
2. Can identify S&S of relapse 2. Parents could identify S&S of the disease returning

Concept Mapping- Colton Graham

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3. Understand treatments that must be

Performed at home.
4. Educated on medications and proper
Administration of drugs
5. Educate them on needs within the
House and making sure they can provide
The infant with proper care.
6. Know when to contact HCP
3. Parents understand what they are required to do in order
To care for the infant at home
4. Parents are informed on timing of meds, dosage, and how
To administer the drugs
5. Parents are able to properly prepare house for returning
Home and set it up for the needs of the infant
6. Parents understand when it is urgent and the HCP needs
Contacted.

Evaluation of outcomes objectives:

The parents were able to explain how to care for the infant at home until full recovery has occurred and how to
prevent a relapse of the issue.

Concept Mapping- Colton Graham

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Concept Mapping- Colton Graham

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Concept Mapping- Colton Graham