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Concept Mapping
4832 Nursing Care of Children and Families
Lexy Herman
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#1 Ineffective Airway
Clearance #2 Ineffective Breathing #3 Impaired Gas Exchange
Pattern
Supporting data: Supporting data:
Tracheobronchial Supporting data: Respiratory effort:
secretions Cough retractions – intercostal,
Nasal suction prn Dyspnea subcostal, substernal,
RR: 40 HR: 132 Tachypnea suprasternal
Oxygen treatment 1.5 L Nasal flaring Lung sounds: Wheezing
nasal cannula Nose: congested: sodium HR: 132
Intercostal, subcostal, chloride (Ocean) ).65% RR: 40 Sp02: 95
substernal, suprasternal nasal spray Oxygen: 1.5 L nasal
retractions cannula
Wheezing
Non-productive cough
Pale

#4 Deficient Fluid Volume

Respiratory Syncytial Virus (RSV) #5 Imbalanced Nutrition
Supporting data:
Key assessment: Supporting data:
Decreased urine output Nose: congested
Respiratory effort: retractions – intercostal, Weakness
Inadequate oral intake subcostal, substernal, suprasternal
Lung sounds: Wheezing Pale mucous membranes
Dry mucous membranes Cough: non-productive
Temp: 98.8 F HR: 132 RR:40 SpO2: 95 Dyspnea
Poor skin turgor Skin color: pale
Cap refill: less than or equal to 2 seconds
Oxygen: 1.5 L nasal cannula

#6 Caregiver Knowledge
Deficit #8 Caregiver Role Strain

Supporting data: Supporting data:

Isolation #7 Parental Anxiety Single mother

Disease process Supporting data: Had another child at home

Signs and symptoms of
respiratory distress
Medication
Parent voice concerned that Alteration in sleep patterns:
the child had RSV before mother voiced she didn’t
but this time seems worse sleep well
Parent never left bed side

Parent had a
nervous/anxious facial
expression
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Problem # 1 Ineffective Airway Clearance:

General Goal: Maintain clear, open airway

Predicted Behavioral Outcome Objective (s): The patient will maintain clear, open airways as
evidence by normal breath sounds (no wheezing), and normal rate (30-55 for age) of respirations
on the day of care.

Nursing Interventions Patient Responses

1. Assess airway for patency 1. Airway was patent

2. Assess respirations 2. RR: 40
3. Auscultate breath sounds 3. Wheezing on expiration
4. Assess cough 4. Patient had non-productive cough
5. Provide periods of rest 5. Patient slept for an hour w/o disturbance
6. Maintain a clear airway by 6. Patient cried while suctioning
suctioning
7. Provide oxygen 7. Patient had nasal cannula with 1.5L of
oxygen

Evaluation of outcomes objectives: Goal was partially met. Patient’s respiratory rate was in normal range for
his age (age: 7 months old) (RR:40) but still had expiratory wheezes.
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Problem # 2 Ineffective Breathing Pattern:

General Goal: Maintain an effective breathing pattern

Predicted Behavioral Outcome Objective (s): The patient will maintain an effective breathing
pattern, as evidenced by relaxed breathing at normal rate (30-55 for age) on the day of care.
(age: 7 months old)

Nursing Interventions Patient Responses

1. Assess respiratory status 1. Respiratory effort: retractions- intercostal,

subcostal, substernal, suprasternal

3. Auscultate breath sounds 3. Wheezing on expiration

4. Assess pulse rate and oxygen 5. HR:132 SpO2: 95

saturation
5. Maintain a clear airway by 6. Patient cried when suctioning
suctioning
6. Monitor vital signs 6.. Temp: 98.8 F HR:132 RR:40 SpO2:95
7. Provide oxygen 7. Patient had nasal cannula with 1.5L of
oxygen

Evaluation of outcomes objectives: Goal was met. Patient’s respiratory rate was 40 at 1600 and 44 at 1800
which is a normal rate for his age.
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Problem # 3 Impaired Gas Exchange:

General Goal: Demonstrate improved ventilation and adequate oxygenation

Predicted Behavioral Outcome Objective (s): The patient will maintain an oxygen saturation
above 94% on the day of care.

Nursing Interventions Patient Responses

1. Monitor respiratory rate, 1. Respiratory effort: retractions- intercostal,

depth, and ease of subcostal, substernal, suprasternal
respirations
2. Auscultate breath sounds 2. Wheezing on expiration

3. Monitor oxygen saturation 3. SpO2: at 1600: 95% 1700:97% 1800: 98%

continuously using pulse 1900: 98%
oximetry
4. Provide supplemental oxygen 4. Patient had nasal cannula with 1.5L of oxygen

Evaluation of outcomes objectives: Goal was met. Patient’s oxygen saturation was 95% at 1600, 97% at 1700,
98% at 1800 and 98% at the end of my shift at 1900.
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Problem #4 Deficient Fluid Volume:

General Goal: Patient will have fluid balance

Predicted Behavioral Outcome Objective (s): The patient will maintain urine output of 2
ml/kg/hour on the day of care.

on the day of care.

Nursing Interventions Patient Responses

1. Monitor patient for sunken
eyes. Decreased tears, dry
mucous membranes, poor skin
turgor and decreased urine
output
2. Weigh
3. Feed patient Pedialyte
4. Maintain I & O record
5. Monitor vital signs
1. Patient had dry mucous membranes and no
other symptom listed
2. Patient’s weight was 7.64kg
3. Patent had 60ml of Pedialyte
4. Intake 60ml Output 74ml
5. Temp: 98.8 F HR:132 RR:40 SpO2:95

Evaluation of outcomes objectives: Goal was met. Patient’s output during my shift was 74ml total. The
patient’s weight is 7.64kg. 2ml/kg/hour would be 15.28 ml an hour and total 61.12 ml for 4 hours (my shift).
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Problem #5 Imbalanced Nutrition:

General Goal: Patient will consume adequate nourishment

Predicted Behavioral Outcome Objective (s): The patient will consume at least 60ml of
Pediaylte on the day of care.

Nursing Interventions Patient Responses

1. Weigh and measure length of 1. Patient’s length was 73 cm and weight was
of patient 7.64 kg
2. Plot measurements on growth 2. 10th percentile in weight and 90th percentile in
chart length
3. Feed patient Pedialyte 3. Patient had 60ml of Pedialyte and tolerated it
well

Evaluation of outcomes objectives: Goal was met. Patient consumed 60ml of Pedialyte during my shift.
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Problem # 6 Caregiver Knowledge Deficit:

General Goal: Caregiver will gain more knowledge about the patient’s illness

Predicted Behavioral Outcome Objective (s): The caregiver will explain disease state and
understand treatments on the day of care.

Nursing Interventions Patient Responses

1. Educate caregiver on isolation 1. Caregiver verbalized she now understand

Precautions why personal protective equipment is
necessary
2. Educate caregiver about RSV 2. Caregiver expressed she now had a better
understanding of RSV

3. Grant a calm and peaceful 3. Caregiver appreciated clustering of nursing

environment with little activities which allowed her and the patient
interruption to allow caregiver a period of rest
to focus

Evaluation of outcomes objectives: Goal was met. Caregiver explained that RSV is a respiratory tract infection
and is contagious and that’s why the patient is in isolation.
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Problem # 7 Parental anxiety:

General Goal: To decrease the parent’s anxiety

Predicted Behavioral Outcome Objective (s): The parent will verbalize absence or decrease
distress on the day of care.

Nursing Interventions Patient Responses

1. Assess the client’s level of 1. Caregiver had moderate level anxiety

anxiety and physical reactions
to anxiety.

2. Use empathy to encourage the 2. Caregiver understand anxiety was a normal

client to interpret the anxiety response in this situation
symptoms as normal
3. Intervene in care to remove 3. Caregiver was appreciative when I stepped in
Sources of anxiety and helped with the patient’s care
4. Explain all activities, 4. Caregiver appreciated being told every thing
Procedures, and issues that that was going to happen before it did
involve the patient. Use
nonmedical terms and calm,
slow speech

Evaluation of outcomes objectives: Goal was met. Caregiver reported she felt better today than the day before.
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Problem # 8 Caregiver Role Strain

General Goal: Caregiver will have relief from stress

Predicted Behavioral Outcome Objective (s): The caregiver will take a break and leave the room
on the day of care.

Nursing Interventions Patient Responses

1. Regularly monitor signs of 1. Caregiver had no signs of depression but did

depression, anxiety, burden.
and deteriorating physical
health in the caregiver
2. Identify potential caregiver
resources
3. Arrange for intervals of
respite care
express some anxiety about her child being ill
2. Caregiver identified that her mother comes and
helps out
3. Caregiver was able to get something to eat while
I stayed in the room with the patient

4. Encourage caregiver to talk 4. Caregiver expressed that her child had RSV
about feelings, concerns and before and felt “this time was worse”
fears.

Evaluation of outcomes objectives: Goal was met. Caregiver was able to take a break and get something to eat
while I stayed with the patient.