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Concept Mapping
4832 Nursing Care of Children and Families

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Key Problem 1
 Impaired Gas Exchange Key Problem 5 Key Problem 2
Supporting Data:  SLOPPY COPY
Impaired Urinary  Ineffective Airway
 O2 reported at 80-88 before Elimination Clearance
oxygen administration Supporting Data: Supporting Data:
 Respiratory panel film array  INC BUN: 29  Increased production of
positive for  INC Creatinine: 1.54 secretions
Rhinovirus/Enterovirus  Anuria  Use of suctioning
 X-Ray of chest showed lungs  Reduced glomerular  Abnormal breath
hyperinflated filtration rate resulting in sounds: wheeze
 Continuous Oxygen the kidney’s inability to  Bronchospasm
Administration through nasal excrete  Meds: Albuterol
cannula- only .325L d/t weening
off
 Nasal Suctioning
 Nebulizer used- Albuterol
 Destruction of alveoli
 Inability to move secretions
 Reduced tolerance for activity Reason For Needing Health Care Key Problem 7
Acute on Chronic Respiratory Failure +  Acute Pain
End Stage Renal Failure Supporting data:
Key Problem 4 Key Assessments  Facial Grimacing
 Imbalanced Nutrition: Less Than Skin: Nasal Cannula taped to face  Crying
Body Requirements GI :I&O, d/t kidney dysfunction  RR & BP
Supporting Care Respiratory: lung sounds, respiratory effort increased while
 Weight in 1st%ile, (6.185kg) and pulse oximetry d/t respiratory failure suctioning
 Loss of muscle mass Nutritional Status  FLACC scale used
 Poor muscle tone Temp + Vitals score 8
 Hypotonia
 Height in 68th%ile

Key Problem 3 Key Problem 6

Supporting Data:
Key Problem 8
 Caregiver Role Strain
Supporting data:
 Lack of visitation by
parents
 Chronically Ill child
 Child loves to be held
due to lack of parent
 Risk for infection  Decreased Cardiac Output
Supporting data:
 Malnutrition:  Fluid imbalances affecting
weight in 1st%ile circulating volume,
 Decreased myocardial workload
platelets: 202  Alteration in rate, rhythm,
 Decreased cardiac conduction
Lymphocytes: 34  Electrolyte imbalances:
 Inadequate Sodium 130, Chloride 90
primary defenses:  Urea
stasis of secretions  Deposition of calcium
phosphate
 Broviac Catheter in right
upper chest
 Use of Alteplase (Cathflo)

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Problem # 1: Impaired gas Exchange

General Goal: Participate in treatment regimen within the level of ability/situation.

Predicted Behavioral Outcome Objective (s): The patient will Demonstrate improved ventilation
and adequate oxygenation of tissues by ABG’s WNR and be free of symptoms of respiratory
distress on day of care.

Nursing Interventions:
1. Assess and record respiratory rate, depth. Note the use of accessory muscles,
pursed-lip breathing, inability to speak or converse.
2. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%
3. Provide humidified oxygen as ordered
Patient Responses:
1. Patient showed a normal respiratory rate and depth
2. Patient’s O2 saturation was maintained within normal limits
3. Patient was administered oxygen as ordered and did not show signs of respiratory
distress
4. Patient was suctioned as ordered and showed signs of a clearer airway and
reduction of productive cough.

Evaluation of outcomes objectives: The interventions in this situation helped the patient maintain an adequate
gas exchange and kept vital signs within normal limits. Goal met.

Problem # 2: Ineffective Airway Clearance

General Goal: Maintain airway patency with breath sounds clear/clearing.

Predicted Behavioral Outcome Objective (s): The patient will demonstrate behaviors to improve
airway clearance, cough effectively and expectorate secretions on day of care.

on the day of care.

Nursing interventions: The nurse will….

1. Observe characteristics of cough (persistent, hacking, moist). Assist with measures
to improve the effectiveness of cough effort.
2. Suction the patient to break up and reduce secretions
3. Administer bronchodilators
Patient Responses:
1. Improved coughing effort
2. Patient showed lack of productive cough after suctioning
3. Patient showed less labored breathing after administration of Albuterol
Evaluation of outcomes objectives: The interventions in this situation allowed for the patient to maintain
airway patency with breath sounds and improved airway clearance. Goal Met.

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Problem 3: Risk for infection

General Goal: Patient remains free of infection
Predicted Behavioral Outcome Objective (s): Patient will remain free of infection by
participating in breathing exercises and finishing prescribed feeds on day of care

Nursing Interventions, The nurse will…

1. Obtain sputum specimen by deep coughing or suctioning for Gram’s stain,
culture, and sensitivity
2. Demonstrate and assist the patient in the disposal of tissues and sputum. Stress
proper handwashing, and use gloves when handling or disposing of tissues,
sputum containers
3. Limit visitors. provide masks and gowns as indicated.
Patient responses:
1. Patient was negative for infection upon cultures
2. Patient was not exposed to improper handwashing, absence of gloves, or any
other means of infectious disease.
3. Patient was protected by being cleaned and having visitors wear PPE as indicated
due to risk for infection.

Evaluation of outcomes objectives: The interventions in this situation allowed for

the patient to remain free of infection when previously listed as a high risk for
infection. Goal met.

Problem 4: Imbalanced Nutrition: Less Than Body Requirements

General Goal: Display progressive weight gain toward the goal as appropriate.
Predicted Behavioral Outcome Objective (s): Patient will Demonstrate
behaviors/lifestyle changes to regain and/or maintain an appropriate weight.
Nursing Interventions: Nurse will…
1. Auscultate bowel sounds to assess for gastric motility and constipation related to
limited fluid intake and hypoxemia
2. Feed the patient high calorie foods to maintain body weight and muscle mass
3. Weigh the patient and record
Patient responses:
1. Patient had bowel sounds present and did not show diminished or hypoactive
bowl sounds
2. Patient ate the prescribed feedings fully
3. Patient was cooperative in taking weight related to caloric needs which is helpful
in the adequacy of developing a nutritional plan

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Evaluation of outcomes objectives: These interventions helped the patient

regain and maintain an appropriate weight and showed a progressive gain
towards appropriate weight. Goal Met.

Problem 5: Decreased Cardiac Output

General Goal: Improve cardiac output

Predicted Behavioral Outcome Objective (s): Maintain cardiac output as

evidenced by BP and heart rate within patient’s normal range; peripheral
pulses strong and equal with prompt capillary refill time.

Nursing interventions: Nurse will...

1. Evaluate heart sounds, BP, peripheral pulses, capillary refill, vascular
congestion, temperature, and sensorium or mentation.
2. Assess activity level, response to activity.
3. Monitor Electrolytes (potassium, sodium, calcium, magnesium), BUN and
Creatinine
Patient Responses:
1. Patient did not show signs of sudden hypotension, narrow pulse, diminished
or absent peripheral pulses, JVD, pallor, or medical emergencies
2. Patient did not show signs of weakness associated with heart failure and
anemia
3. Patient’s electrolytes were still out of normal range but did not get worse and
most of them improved including creatinine and sodium.

Evaluation of outcomes objectives: These interventions helped the patient

maintain cardiac output and avoid signs of decreased cardiac output. Goal
met.

Problem 6: Impaired Urinary Elimination

General Goal: Patient shows signs of healthy urinary elimination
Predicted Behavioral Outcome Objective (s): Patient will urinate without
bladder distention, urine retention, pain or discomfort, and will eliminate a
normal amount of urine on day of care.
Nursing interventions: Nurse will…
1. Review for laboratory test for changes in renal function.
2. Palpate bladder and assess color of urine
3. Determine client’s usual daily fluid intake
Patient Responses:
1. Patient did not show any negative changes in renal function on day of
care.
2. Patient did not show signs of urinary retention or increased urination.
Patient’s urine was also appropriately colored

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3. Patient took in the required number of fluids for the day based on weight
of 6.2 kg
Evaluation of outcomes objectives: These interventions helped the
patient remain free of impaired urinary elimination, bladder distention,
urine retention, pain, and discomfort. Goal met.

Problem 7: Acute Pain

General goal: Patient will be without pain
Predicted Behavioral Outcome Objective (s): The patient will remain
free of unpleasant emotional and sensory experience and show a lower
sign of pain on the FLACC scale by end of shift

Nursing Interventions: The nurse will:

1. Monitor and record patient’s vital signs to report an increase of pain if
necessary
2. Perform a comprehensive assessment of pain location, onset,
characteristics, and frequency
3. Nurse will rate the patient’s pain on the FLACC scale

Patient responses:
1. Patient did not show an increase in vital signs such as HR, BP, RR,
regarding pain
2. Patient did not show signs of pain during assessment of specific
locations.
3. Patient showed a FLACC rating of 4 at the end of shift-improving
from 8 at the beginning

Evaluation of outcome objectives: These interventions helped the

patient remain fee of pain and through assessment the patient was
able to be evaluated for acute pain during the shift. Goal met.

Problem 8: Caregiver Role Strain

General Goal: Assess for neglect and abuse of the care recipient
Predicted Behavioral Outcome Objective (s): The caregiver-care
recipient relationship will be improved, and the care recipient will
receive more safety and bonding by end of stay in hospital.

Nurse interventions. Nurse will…

1. Ascertain the caregiver’s knowledge and ability to implement
patient care, including bathing, skin care, safety, nutrition,
medications, and ambulation.
2. Evaluate the family communication pattern.

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3. Evaluate the caregiver’s appraisal of the caregiving situation, the

level of understanding, and willingness to assume caregiver role.
Patient Responses
1. Patient caregiver is informed of the fundamental guidance needed
to enhance the relationship to the recipient
2. Patient is informed that mutually satisfying relationships promote a
therapeutic caregiving experience.
3. Patient caregiver did not show up during the day of care.
Evaluation of outcome objectives: These interventions are good
means of helping the child-parent relationship healthily. These
planned interventions could not be fulfilled fully because of the
lack of presence of the caregiver. Goal not met.

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