Concept Mapping

4832 Nursing Care of Children and Families

 Key Problem 2: Alteration in nutrition/fluid
volume

Supporting Data:
-dehydration d/t nausea and vomiting
-chemotherapy side effects Key Problem 3: Risk for Impaired skin
Key Problem 1: Risk for infection integrity
-poor skin turgor
-dry mucous membranes
Supporting Data: Supporting Data:
-tachycardia (HR 130)
-bone marrow suppression d/t -effects of chemotherapy and radiation
-polyuria
chemotherapy -altered nutritional state
-dry/cracked lips
-central venous access port -fecal and urinary incontinence
-neutropenic -immobility and inactivity r/t pain and
-poor nutrition malaise
-skin ulcers -dec. albumin level
-invasive procedures -impaired circulation

Reason For Needing Health Care:

Antineoplastic Chemotherapy

Key Assessments:
-vital signs: HR, RR, temp, BP
-CBC -I&O -skin assessment
-lab values -skin turgor
-capillary refill -weight -pulse oximetry

Key Problem 4: Risk for Altered Oral Key Problem 5: Fatigue Key Problem 6: Caregiver Role Strain
Mucous Membranes
Supporting Data: Supporting Data:
Supporting Data: -lack of energy -single mother
-side effects of chemo treatment -lethargy/listlessness -part time job
-dehydration -disinterest in surroundings -financial responsibilities
-dec. platelets -chemo tx. -expressed concern about losing job
-malnutrition -anemia -knowledge deficit
-immunocompromised -physical inactivity -no time for self-care
-inadequate oral hygiene -anxiety/stress communicated about
child’s illness

Problem #1: Risk for infection

General Goal: Identify and participate in interventions to prevent/reduce risk of infection
 Predicted Behavioral Outcome Objective (s):

The patient will remain afebrile and show no signs/symptoms of infection during shift

Nursing Interventions Patient Responses

1. Emphasize personal hygiene 1. Pt’s mother acknowledged importance of performing proper

2. Monitor temperature hygiene techniques
3. Promote adequate rest 2. Pt temperature was not elevated during time of care
4. Avoid/limit invasive procedures 3. Pt slept for about two hours during shift
5. Check central line dressing for signs 4. No invasive procedures were performed
of infection 5. Central line showed no signs of infection such as drainage,
6. Monitor CBC erythema, burning or stinging
7. Administer antibiotics as indicated 6. WBC remained 4.6 which indicates no sign of infection
8. Encourage fluid intake 7. Pt received Bactrim (120mg PO M-W-F)
8. Pt drank about 320mL of juice during shift

Evaluation of outcomes objectives:

Pt remained free from infection, as evidenced by normal vital signs and absence of signs and symptoms of
infection.

Problem # 2: Alteration in nutrition/fluid volume

General Goal: Pt will display adequate fluid balance evidenced by moist mucous membranes,
good skin turgor, and adequate urinary output
Predicted Behavioral Outcome Objective (s):

The patient will have decreased nausea and increase PO intake at end of shift
Nursing Interventions Patient Responses

1. Monitor I&O 1. Pt output was 800mL and PO intake was 620mL during shift
2. Monitor VS (pulses, skin turgor, 2. Pt had 2+ pulses, normal BP, elevated HR, normal skin turgor,
mucous membranes) and dry mucous membranes
3. Inc. fluid intake (2,000ml day) 3. Pt began drinking more throughout the day
4. Monitor CBC, electrolytes, 4. CBC, electrolytes, and albumin remained normal
serum albumin 5. Pt food intake was poor; ate a couple crackers during shift
5. Monitor daily food intake 6. Inc. in calories and protein was discussed with mother
6. Encourage high calorie and 7. Pt showed no signs of nausea during shift
high protein diet
7. Assess pt. for nausea (give antiemetics)

Evaluation of outcomes objectives:

Pt showed slight increase in PO intake but was still dehydrated according to his I&O. Mucous membranes
Problem # 3: Risk for impaired skin integrity
were dry at end of shift, skin turgor was normal and vitals remained stable.
General Goal: Pt will participate in techniques to prevent complications/promote healing as
appropriate

Predicted Behavioral Outcome Objective (s):

The patient will have no new signs of impaired skin integrity (ulcer formation, lesions) at end of
shift
 Nursing Interventions Patient Responses

1. Assess skin frequently for signs of 1. Pt had pressure ulcer on left buttocks but no sign of worsening
skin breakdown or new locations of skin breakdown
2. Encourage fluid intake 2. Pt was encouraged to drink fluids throughout day; drank total
3. Turn/reposition pt q 2hrs of 620mL during shift
4. Apply moisture barrier 3. Pt was repositioned every hour
5. Assess skin and IV site for edema, 4. Antibiotic cream was applied to left buttocks where skin
tenderness or erythema breakdown was evident
6. Pat skin instead of rub when drying 5. Skin/IV site showed no signs of infection or potential breakdown
6. Patting rather than rubbing was done while cleansing patient

Evaluation of outcomes objectives:

Pt’s skin remained intact and no new signs of skin breakdown or impaired skin integrity were evident.

Problem #4: Risk for Altered Oral Mucous Membranes

General Goal: Pt. will demonstrate techniques to maintain/restore integrity of oral mucosa

Predicted Behavioral Outcome Objective (s):

Pt will display intact mucous membranes that are pink, moist, and free of
inflammation/ulcerations at end of shift

Nursing Interventions Patient Responses

1. Assess dental/oral hygiene 1. Pt showed no signs of poor oral hygiene

2. Note changes in mucous membrane 2. Mucous membranes were dry, but intact
integrity 3. Glycerin swabs were used when performing oral hygiene for pt
3. Initiate oral hygiene (mouthwash or 4. Soft toothbrush was used during oral care
glycerin swabs) 5. Lip balm was applied to prevent further cracking/dryness of lips
4. Brush w/soft toothbrush 6. No signs of thrush were present during assessment
5. Keep lips moist w/lip balm to prevent 7. Fluid intake was encouraged throughout entire shift (pt drank
drying/cracking 620mL during shift)
6. Monitor for signs of thrush
7. Encourage fluid intake

Evaluation of outcomes objectives:

Pt continued to have dry mucous membranes, but showed no signs of thrush or cracked lips.

Problem #5: Fatigue

General Goal: Pt will have an overall inc. level of energy throughout day
 Predicted Behavioral Outcome Objective (s):
The patient will have improved energy and participate in ADLs during shift

Nursing Interventions Patient Responses

1. Assist w/self-care needs 1. Pt was assisted with doing ADLs

2. Encourage pt to do ADLs (self-bathing,
sitting in chair, walking)
3. Monitor physiological response to
activity (HR, BP, RR)
4. Perform pain assessment
5. Provide oxygen as needed
6. Inc. activity level if pt is able
2. Pt was able to feed self but needed assistance walking and bathing
self
3. Pt’s vitals did not significantly change d/t inc in activity
4. Pt showed no signs of pain (grimacing, guarding)
5. SpO2 was normal; pt did not need oxygen
6. Pt was encouraged to sit up but unable to do so d/t extreme fatigue

Evaluation of outcomes objectives:

Pt remained fatigued throughout the day but showed slight increase in level of energy towards the end of shift.

Problem # 6: Caregiver Role Strain

General Goal: Caregiver shows confidence in performing the caregiver role by meeting patient’s
physical and psychosocial needs

Predicted Behavioral Outcome Objective (s):

The caregiver will exhibit less stress and improved knowledge of care necessary for patient at
end of shift
Nursing Interventions Patient Responses

1. Assess family resources and 1. Pt’s cousins visited and mother was always at bedside
support systems 2. Mother seemed emotionally drained but expressed importance
2. Evaluate caregiver’s physical and of caring and being there for her son
mental health status 3. Mother was encouraged to take some time for herself and received
3. Encourage rest/alone time of caregiver massage at the hospital courtesy of staff
4. Assess sleep pattern of caregiver 4. Caregiver stated she gets adequate amount of sleep (about 6 hours)
5. Evaluate caregiver’s knowledge of pt 5. Mother is aware and knowledgeable about pt’s needs
needs 6. Mother was encouraged to take care of herself mentally and
6. Encourage self-care physically before taking care of the pt
7. Assess for neglect and abuse of pt 7. No signs of neglect or abuse of the pt were observed
8. Evaluate the caregiver’s willingness 8. Mother stated she is very willing to take care of her son
to assume the caregiver role

Evaluation of outcomes objectives:

Mother acknowledged the importance of caring for herself and stated she would rest/have more alone time.