CLINICAL CONCEPT MAP

1. Readiness for Enhanced
Nutrition
Supporting Data: Successful bowel
movement, absence of vomiting after
PO intake, expresses willingness to
enhance nutrition by reaching for
bottle

2. Interrupted Family
Process

Labs: TPN panel, metabolic panel,
glucose check
Meds:

Pt Initials: AW
Age: 10 months
Medical Diagnoses:

3. Risk for Infection
Supporting Data:
abdominal incisions and
presence of tubes, PICC
line, TPN
Labs: CBC, glucose, any
cultures if necessary
Meds: Prophylactic
antibiotics post op

(Include secondary diagnoses)
Bowel Obstruction, Post Op Day 10

Supporting Data: multiple
hospitalizations within first
year of life, history of surgery,
history of birth complications,
vocalization of stress,
unpredictable illness course,
discharge needs, economic
hardship as evidence by low
socioeconomic status, works at
Wal-mart- job conflictions
with care
Labs
Meds
5. Risk for Acute Pain
related to extensive
exploratory surgery

4. Risk for Imbalanced
Nutrition: less than body
requirements related to a
risk for altered body
composition
Supporting Data: TPN
dextrose 14% 32mL/hr, 768
mL per day continuous, Fat
emulsion 20% 250mL bag
2.5mg/kg 4.11mL/hr,
prolonged NPO, altered GI
tract function, increased
metabolic rate
Labs: TPN panel
Meds:

Supporting Data: bowel
inflammation, intraperitoneal
lesions, return to PO nutrition,
current FLACC score = 0
Meds: No current meds were
listed, previously Tylenol IV
and Morphine PRN for first 7
days post op

1. Nursing Interventions:
Educate mother on proper nutrition for patient,
monitor bowel movements and bowel sounds,
monitor gas, assess tolerance of PO intake,
determine patterns of hunger
2. Nursing Interventions:
Assess caregiver-care recipient relationship,
assess familial communication patterns, assess
family resources, determine knowledge and
ability to provide care, encourage
identification of resources whether family or
community, teach stress-reducing techniques,
provide ample time to discuss concerns,
provide illness information, management
strategies, and signs and symptoms to look for
management (Gulanick & Myers, 2013).

3. Nursing Interventions: Assess patient
temperature, monitor incision for redness,
drainage, swelling, and increased pain, wash
hands and maintain aseptic technique during
dressing changes, monitor TPN dextrose levels
and influence on patients glucose, monitor
PICC line- watch for redness, swelling, and
irritation, only change when needed,

4. Nursing Interventions: maintain potassium
<3.89 mEq/kg/day and calcium <1.94
mEq/kg/day, consult a dietician regarding TPN
order, TPN order was 10% dextrose and
glucose levels were elevated, dextrose was
then increased to 14% and glucose dropped ,
monitor daily intake and output, assess for the
signs and symptoms of electrolyte imbalance,
monitor triglycerides, assess
hyper/hypoglycemia,
5. Nursing Interventions:
Assess signs and symptoms associated with
pain, monitor vitals, assess activity,
personality, fatigue, and comfort level

1. Expected Outcome: Patient engages in feeding
herself with a bottle and tolerates PO feeding.
Evaluation: The patient was able to appropriately reach
for the bottle and tolerate PO feeding on the day of
discharge as evidence by the absence of emesis. Last
bowel movement was recorded 9/29.
2. Expected Outcome: Before discharge, the
caregiver will express satisfaction with caregiving
role, demonstrate confidence in post discharge care,
recognize available resources, and demonstrate
flexibility and understanding towards health issues.
Evaluation: The patient’s primary caregiver
demonstrated satisfaction after feeding the patient on the
day of discharge by smiling and interacting with the
patient positively. She expressed excitement to get
home, as well as, appropriate understanding of signs and
symptoms that would indicate return to the hospital. The
caregiver addressed day care as an available resource in
the community. She discussed helpful sources within
her family as her mother, grandmother, and brother.
3. Expected Outcome: Patient remains free of
infection, as evidence by healing of the incision and
normal vital signs during hospitalization.
Evaluation: Patient was free of infection throughout
stay in the hospital as evidence by a temperature of 37.1
and a heart rate of 116.. Mother was educated on
cleaning the incision and dressing the incision for
prevention of infection at home. The mother was also
educated to not bathe the child in a full tub, rather have
the child sit in a few inches of water to prevent the
water from infecting the incision site.
4. Expected Outcome: The patient will maintain
normal serum electrolytes and serum glucose while
hospitalized. Mother will be educated on signs and
symptoms of hypoglycemia before discharge.
Evaluation: The patient showed no signs of
hypoglycemia before discharge. The mother was
educated and given discharge orders while I was leaving
for the day.
5. Expected Outcome: Patient exhibits comfort
demonstrated by a return to baseline personality and
activity.
Evaluation: The patient showed no signs of pain, had
normal vital signs as indicated earlier, and a
positive overall demeanor as evidence by no crying
and return to personality.

Resources
Gulanick, Meg; Myers, Judith L. (2013-02-05). Nursing Care Plans: Nursing Diagnosis
and Intervention (Kindle Location 1329). Elsevier Health Sciences. Kindle Edition.