Assessment and Concept Map Care Plan

For
Pediatric Patient

Madison Tibbetts
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#2 Key Problem: #4 Key Problem: #1 Key Problem:

Altered GI function Altered Nutrition Possible Death of
Supporting Data: Supporting Data: Intestinal Tissue
Inability to pass stool NPO for surgery Supporting Data:
NPO from surgery – Cannot eat until bowel Lack of blood flow to
nothing to pass function returns intestine from malrotation

#5
Reason For Needing Health Care:
Malrotation of the Intestine Key Problem:
#3 Key Problem: Key Assessments: Altered Skin Integrity
Risk for Infection GI Supporting Data:
Supporting Data: Intake & Output Surgical incision
Surgical incision Bowel Sounds Not ambulating much d/t
Open to air Abdomen Distention pain/discomfort
Diet NPO from surgery Surgical Incision Diet NPO from surgery
Decreased ambulation d/t Skin Assessment
pain from surgery Vital Signs
Labs/Imaging
#8

Key Problem: #7 Key Problem: #6 Key Problem:

Impaired Mobility Pain Parental Anxiety
Supporting Data: Supporting Data: Supporting Data:
Doesn’t walk as frequently Surgical incision Have been dealing with
b/c of pain PCA pump these issues since birth
Lengthy hospital stay Pt.’s self-report of pain Other children at home
Live far away
Lengthy hospital stay
Hospital bills

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

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Problem #1: Possible Death of Intestinal Tissue

General Goal: maintain blood flow to intestines

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

on the day of care.

Nursing Interventions Patient Responses

1. keep pt. NPO 1. pt. remained NPO before surgery

2. manage nutrition/fluids
3. reducing anxiety/fear
4. maintaining airway
5. managing acute pain
2. IV fluids
3. nerves were calmed after talking
through procedure
4. pt’s airway remained clear/patent
5. pain meds were administered as needed

Evaluation of outcomes objectives: surgery went well, and pt. is managing pain well.

Problem #2: Altered GI function

General Goal: return to normal GI function

Predicted Behavioral Outcome Objective (s): The patient will…… take measures to help
facilitate bowel movement
on the day of care.

Nursing Interventions Patient Responses

1. PO fluids 1. pt. drank 2 cups of water

2. high fiber diet 2. pt. did not eat during shift but was
educated on what choices to get
3. encourage ambulation 3. pt. walked through the hall twice
4. make a toileting schedule 4. educated pt. on q2 hour toilet schedule
5. abdominal massage 5. educated pt. how to massage abdomen to
help with the passing of stool

Evaluation of outcomes objectives: pt. did not have a bowel movement yet but did pass gas.

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

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Problem #3: Risk for Infection

General Goal: keep pt. free from infection

Predicted Behavioral Outcome Objective (s): The patient will…… learn about the signs and
symptoms of infection and when to notify nurse/physician
on the day of care.

Nursing Interventions Patient Responses

1. monitor temperature 1. pt’s temperature remained normal

2. monitor labs 2. pt’s labs were within normal range
3. assess for redness around 3. no redness around site of incision
incision site
4. assess for drainage 4. no drainage in/around incision
5. assess for pain 5. pt reported some pain but nothing
extreme

Evaluation of outcomes objectives: pt. was educated on the signs and symptoms of infection and was able
to remain infection free during the shift.

Problem #4: Altered Nutrition

General Goal: maintain nutrition status

Predicted Behavioral Outcome Objective (s): The patient will…… remain hydrated until NPO
diet order changes
on the day of care.

Nursing Interventions Patient Responses

1. monitor hydration status 1. pt had good skin turgor

2. monitor serum electrolytes 2. pt’s electrolytes were within the normal
ranges
3. daily weights 3. pt. was weighed & there was no decrease
4. assess for water retention 4. no signs of edema
5. monitor intake & output 5. pt’s intake & output was recorded in
chart
Evaluation of outcomes objectives: maintained pt’s hydration status while NPO for surgery

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

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Problem #5: Altered Skin Integrity

General Goal: maintain pt’s skin integrity

Predicted Behavioral Outcome Objective (s): The patient will…… take measures to preserve
her skin
on the day of care.

Nursing Interventions Patient Responses

1. change positions frequently 1. pt. was reminded q 2 hours to turn/

2. encourage ambulation
3. keep incision site dry
4. elevate heels while in bed
5. moisturize dry skin
change positions
2. pt. ambulated in the hall during shift
3. incision site was kept dry & intact
4. pt’s heels were elevated on pillow while
lying in bed
5. provided moisturizer for dry skin

Evaluation of outcomes objectives: pt’s skin remained free from any marks or wounds besides her
already existing incision site.

Problem #6: Pain

General Goal: manage pain

Predicted Behavioral Outcome Objective (s): The patient will…… remain comfortable and
free of pain
on the day of care.

Nursing Interventions Patient Responses

1. PCA pump 1. pt. was educated on how to use PCA

pump
2. administer pain meds as 2. pain meds were given when requested
ordered
3. supply ice packs 3. ice packs were placed on sore areas
4. supply heating pad 4. heating pad was given as alternative
5. assist with position changes 5. pt. was moved to comfortable position

Evaluation of outcomes objectives: pt. was able to remain comfortable and pain free.

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

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Problem #7: Impaired Mobility

General Goal: increase pt’s mobility

Predicted Behavioral Outcome Objective (s): The patient will…… ambulate as much as
possible
on the day of care.

Nursing Interventions Patient Responses

1. ROM exercises in bed 1. assisted pt. with ROM exercises twice

2. walk pt. to bathroom
3. walk with pt. in halls
4. change positions frequently
while in bed
5. elevate extremities while in
bed
during shift
2. pt. was assisted to bathroom when needed
3. pt. walked through halls twice during shift
4. pt. was reminded to change positions q 2
hours
5. pt’s legs were elevated with pillow while in
bed

Evaluation of outcomes objectives: pt’s mobility was improved and she ambulated as much as she could
throughout the day.

Problem #8: Parental Anxiety

General Goal: easy parent’s nerves

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

on the day of care.

Nursing Interventions Patient Responses

1. keep family up to date 1. family was kept informed on pt’s

condition/plan of care
2. listen to concerns 2. mom voiced concerned to the nurse
3. refer to social work/ 3. social work came to see family
counselor
4. encourage parents to take 4. mom went to eat lunch while pt. slept
breaks/rest periods
5. build relationship with pt. 5. nurse was trusted by pt. & her family
& family

Evaluation of outcomes objectives: parents seemed less stressed about the hospital stay and were able to
relax a little bit more.

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