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Sterling Roberts

Concept Map

#7 Knowledge deficit
#1 Risk for constipation
related to R/T
#4 Risk for Infection
-Decreases bowel -understanding of
motility R/T appendectomy /
-Lack of nerve cells in -Recent ostomy Malone stoma self care
bowl reversal -Being taught how to
-No stimulation to have give self an enema
bowl movement -Appendectomy
though Malone stoma
-Lack of bowl sounds -Malone stoma
postop

#6 Parental Anxiety Reason for Needing Health Care: Risk for impaired
#3
R/T Hirschsprung’s Disease
16 Y.O
skin integrity R/T
-Parent asking -irritation of enemas
constant question throught Malone stoma
about post op Key Assessments: -leakage of stool from no
-Abdominal assessment stimulation to pass a bowl
-Parent not leaving
-Vital signs movement
bedside -Bowel / stool assessment -Red irritated skin around
-Confusion causing -Surgical site assessment stoma and on lower back
anxiety about child’s -Intake and Output
health

#5 Acute pain
#8 Risk for Impaired Comfort #2
R/T Deficient fluid volume R/T
-surgical pain on abdomen and electrolyte imbalance -Surgical pain
from ostomy reversal and R/T -PCD pump
Malone stoma -Abdominal
-Post operation condition
-leakage of stool
-Wound vac places on -Constant enema though discomfort
surgical site stoma -Ambulation causing
-Lack of motivation to pain at surgical site
drink fluids or eat
-Enema causing flushing
of fluids

Problem # ___1____: Risk for constipation

General Goal: Patient will use enema to pass stool
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Predicted Behavioral Outcome Objective (s): The patient will…… verbalizes understanding of
administering enema to self through the Malone stoma on the day of care.

Nursing Interventions Patient Responses

1.1. Show thepatient

Show the patient howhow to administer
to administer 1. Patient was able to comprehend what he
enema
enema was shown
2. Have the patient verbalize how.
2. Have the a patient verbalize how. 2. Patient verbalize what he learned
to give the enema 3. Patient able to clean stoma site after
3. to
have thethe
give enema
patient show nurse how to teaching
3. have
clean the patient
the stoma siteshow nurse how to 4. Patient was able to show nurse how to
4. clean
Ask thethe stomatosite
a patient teach back what administer
4. Was taught
Ask the a patient to teach back what 5. Unable to assess
5. Teachtaught
Was patient how to put tube back 6. Patient passing gas and stool
In when needed to give enema 7. Patient nervous about touching his
5.6. Teach
Monitorpatient howthe
bowel after toenema
put tube back
is given stomach
7. In when needed
Auscultate bowel to give enema 8. Patient guarded because of potential
6.8. Monitor
Feel bowelbowel after
for signs the enema is given
of discomfort pain
7. Auscultate bowel
8. Feel bowel for signs of discomfort
Evaluation of outcomes objectives: Patient was able to learn about his procedure and his future health. Patient
still nervous about his pain and self conscious about his stomach

Problem # __2__: Deficient fluid volume and electrolyte imbalance

General Goal: Patient will drink water throughout the day. Patient will also be on a clear liquid
diet post op
Predicted Behavioral Outcome Objective (s): The patient will… maintain the adequate amount
of fluid for age and weight on the day of care. IV fluids in place for electrolyte replacement /
fluid.

Nursing Interventions Patient Responses

1. Urge the patient to drink enough fluids for 1. Patient will drink fluids when instructed
the fluids lost from bowel movements 2. Family will help child drink enough fluid
2. Encourage family to help eat clear liquids 3. Patient will make sure site is clean and intact
and drink fluids incase of an emergency
3. Make sure IV patient 4. Patient understands IV fluids can be used to
4. Teach patient about what medications can be replenish electrolytes
used to replenish electrolytes 5. Patient said he likes to drink Gatorade
5. Teach patient about other fluids other than 6. No signs of overload
water to replace what was lost 7. Vitals in normal range for patient. Temp –
6. Monitor for fluid overload 36.4, p – 93, resp rate – 22, BP – 153/55
7. Monitor vital signs (normal trend for patient), SPO2 – 96 room
8. Auscultate lung sounds air
8. Lungs sound clear no signs of fluid in lungs
i
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Evaluation of outcomes objectives: Patient was able to use interventions and maintain adequate fluid and
electrolyte balance. Patient learned ways to keep electrolytes in balance with other liquids. Normal vitals signs
for patient

Problem # _______3__________: Risk for impaired skin integrity

General Goal: Patient obtains clean dry and intact skin

 Predicted Behavioral Outcome Objective (s): The patient will… be able to

clean self with help of mother and keep skin clean dry and intact

Nursing Interventions Patient Responses

1.
1. Clean around stoma site 1. Patient felt self conscious and guarded
2. Clean any leakage of stool that 2. Patient was thankful for the help with
3. Monitor skin color and skin irritation cleaning
4. prepare the skin with skin- 3. Skin clean and dry
toughening preparations to keep skin 4. Skin remains strong
around sites strong 5. Patient provided teach back on how to clean
5. Teach patient how to clean how skin 6. Mother showed that she knew what to look
around stoma site for with skin rashes
6. Teach mother how to check for skin 7. Patient guarded from pain
8. No pressure injuries
rashes
7. Check surgical site for skin irritation
8. Check for pressure injuries from
being in bed

Evaluation of outcomes objectives: Patients skin remained clean dry and intact on the day of care. Teaching
provided to continue this care for the stoma site and surgical incisions.

Problem # ___4. Risk for Infection

General Goal: Client will remain free of infection
Predicted Behavioral Outcome Objective (s): The patient will…… maintain normal vital signs
and absence of signs and symptoms of infection on the day of care. WBC labs will remain low.

Nursing Interventions Patient Responses

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1. Nurse will keep hand clean before and 1. Patient and nurse keep hands clean to
after caring for patient fight any germs
2. Education provided on proper hand 2. Patient and family able to wash hands
washing/hygiene correctly or use hand sanitizer
3. Keeping the surgical site clean 3. Parents and patient teach back on
4. Encourage keeping up with fluids how to keep hand cleans before
along with a good diet touching surgical site
4. Patients body will remain healthy and
able to fight off future infections

Evaluation of outcomes objectives: Patients vitals were normal throughout the day and CBC came back with
minor increase in WBCs.

Problem # _______5__________: Acute pain

General Goal: Patient obtains pain goal
Problem # 5: Risk for impaired comfort
General Goal: Pt will have little to no pain

Predicted Behavioral Outcome Objective (s): The patient will…… have a lower
pain level from help with medication and distraction

Nursing Interventions Patient Responses

1. Patient provided with PCA 1. PCA pump pushed with

pump patient was in any pain.
2. Patient ambulating with Unable to overdose self with
supervision from nurse this method.
3. Patient given pain medication 2. Patient in pain when moving
4. Patient provided with but will improve with time
distraction using phone tv and 3. Responded well to
games medication – lower pain
rating
4. Responded well to playing
games and listening to
music on phone

Evaluation of outcomes objectives:

Goal was met. Pt was able to get high pain rating down from post op.

Problem # 6: Parental anxiety

General Goal: Parent’s anxiety will decrease.
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Predicted Behavioral Outcome Objective (s): The patient will… continue to

improve which will then help the parents’ anxiety decrease by end of shift.

Nursing Interventions Patient Responses

1.1. Tell the mother how well she is
handing the situation and
coping with the situation
2. Offer the parent things to drink
like water or coffee
3. Answer any questions the
parent may have about post op
and the child’s condition
4. Encourage the parents to voice
their opinions
1. Helps the parent feel less stress and feel
as if they are doing a good job. The
situation of being in the hospital with a
child is hard for any parent
2. Parent given water
3. Parent able to ask question and gain
knowledge about the situation and
future plan of care
4. Parent felt better after voicing her
frustration with being in the hospital.
Gained trust from parent.

Evaluation of outcomes objectives:

Goal was met. By the end of my day there, the parent felt more relaxed and calmer about the
situation. Parent thanked me for all I have done throughout the day.

Problem # ___7____: Risk for knowledge deficit

General Goal: Patient will understand the surgery he had and how the recovery will go

Predicted Behavioral Outcome Objective (s): The patient will…… be able to explain what
surgery he had and understand his disease.

Nursing Interventions Patient Responses

1. Teach client what a Malone 1. Patient able to understand how the

stoma is stoma works
2. Teach patient how to give self- 2. Patient able to give self-enema with
enema help of family
3. Teach patient how to clean 3. Patient able to clean site effectively
surgical site / parent how to 4. Patient and family understand
clean recovery can take some time for
4. Explain the recovery process abdominal surgery. Patient taught
how to ambulate effectively for
recovery
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Evaluation of outcomes objectives: Patient was able to teach back what was taught to him. Patient now
understand the recovery process and what to expect from it.

Problem # __8__: Risk for Impaired Comfort

General Goal: Patient comfortable throughout the shift

Predicted Behavioral Outcome Objective (s): The patient will… remain comfortable and free of
pain if possible

Nursing Interventions Patient Responses

1. Patient provided water and 1. Patient thanked me for the

other Gatorade assistance
2. Patient provided extra 2. Pillows helped him relax
pillows easier
3. Patients bed changed when 3. Patient thankful for the bed
patient got up to the chair change and stated it feels
4. Patients room cleaned to much better now
make sure it’s a therapeutic 4. Patient and family thanked
environment me for all the help. Room
now clean.

 Evaluation of outcomes objectives: Patient maintains a comfortable environment to assist

with his recovery process.