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Concept Mapping
4832 Nursing Care of Children and Families
Anna Ohlin
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Key problem 1 Key problem 8 Key problem 7

Ineffective airway clearance Acute stomach pain and Anxiety and lack of coping strategy:
Supporting data: distension Supporting data:
- SpO2 86 Supporting data: - Patient voices fear of needles and IV
- Heart rate 149 - Fat, foul smelling stool insertion
- Respiratory rate 29 - Increased stomach girth - Patient retracts and hides
- Non-productive cough - Frequent gas - Patient shakes while taking
- Retractions - Stomach guarding medication
- Crackles with expiration - Lack of pancreatic enzyme - Patient doesn’t show interest in
- HOB elevated - Patient voices abdominal learning treatment
- Pale appearance cramping

Reason for needing health care:

Key problem 2 Cystic Fibrosis Key problem 6
Impaired Gas Exchange Key assessments: Knowledge Deficit
Supporting data: Supporting data:
- Activity intolerance
- Vital signs
- Medication regimen
- Cough - Continuous pulse oximetry (98%)
- Postural drainage
- Dyspnea - Lung sound auscultation (clear)
information
- Hypercapnia - Heart rate (60) - Diet
- Hypoxemia (SpO2 60%)
- Respiratory rate/effort (non- - Exercise importance
- Irritability
- Pale, cyanotic skin color labored) - Chest physiotherapy
- Restlessness - Capillary refill (<3 sec) - Aerosol treatments
- Tachypnea (36 breaths per min) - Skin color/temperature/appearance - Disease process
- Tachycardia (110 bpm) (pink, pale, warm, dry)
- O2 flow rate (2L when needed)

Key problem 4
Imbalanced nutrition: less than Key problem 5
body requirements Activity intolerance
Key problem 3 Supporting data: Supporting data:
Risk for chronic Infections - 10% to 20% below ideal - Dyspnea with standing and
Supporting data: weight activity
- Signs of bronchiolitis - Abnormal eating behaviors - Constant fatigue
- Signs of sinus infection - Abnormal stool patterns - SpO2 84% upon walking
- Lung crackles (diarrhea or constipation) - Respiratory rate 29
- Thick mucus in lungs - Anemia - Heart rate 149
- Thick sputum production - Chronic abdominal - Frequent breaks while
- Fatigue discomfort
walking
- Elevated WBC count (15,000) - Gastroesophageal reflux
- Dizziness
- Low body weight, despite
nutrition intake

Problem # _1__: Ineffective Airway Clearance

General Goal: Patient will show improvement in maintaining a patent airway.
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Predicted Behavioral Outcome Objective (s): The patient will……

Demonstrate improved airway clearance with an SpO2 reading of 93% or higher on the day of
care.

Nursing Interventions Patient Responses

1. Monitor SpO2 during rest periods. 1. Pt. demonstrated an SpO2 reading of 95% while at rest.

2. Monitor signs of respiratory distress. 2. Pt. had few retractions while breathing with no wheezing.

3. Assist pt. with aerosol treatment. 3. Pt. successfully completed an aerosol treatment before

lunch.

4. Assist pt. with coughing to clear secretions. 4. Pt. cleared mucus and secretions from lungs while

coughing.

Evaluation of outcomes objectives:

Pt. met desired outcome of demonstrating improved airway clearance. He was able to complete the needed
treatments and techniques to improve his airway by clearing excess mucus and secretions.

Problem # _2__: Impaired Gas Exchange

General Goal: Patient will improve gas exchange with use of various treatment regiments.

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

Demonstrate improved gas exchange in lungs with the use of daily aerosol treatment, chest
physiotherapy, ambulation and frequent movement on the day of care.

Nursing Interventions Patient Responses

1. Assist pt. with aerosol treatment before bed. 1. Pt. showed airway clearance after treatment with few

secretions.

2. Have pt. receive chest PT at 1500. 2. Pt. successfully had chest PT treatment and loosened

secretions.

3. Encourage ambulation in room Q Hour. 3. Pt. walked around room several times an hour without

distress.
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4. Encourage adequate fluid intake of h2o. 4. Pt. adhered to fluid intake and was able to cough

loose secretions.

Evaluation of outcomes objectives:

Pt. met desired outcome of improving gas exchange. Pt. completed aerosol treatment, chest PT, ambulated
several times, and had adequate fluid intake. Pt. was able to cough loose secretions and breathe with ease.

Problem # _3__: Risk for Chronic Infection.

General Goal: Patient will show no signs of developing a chronic infection due to build-up of
mucus and bacteria within lungs.

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

Adhere to treatment regimen and recognize warning signs of infection to prevent further
complications on the day of care.

Nursing Interventions Patient Responses

1.Institute the appropriate infection control 1. Pt. placed on specific precautions to prevent infection.

precautions.

2. Teach S&S of infection. 2. Pt. correctly stated S&S of what infection would look like.

3. Monitor WBC. 3. Pt. allowed blood draws and understood reason for

monitoring WBC count for infection prevention.

4. Administer antibiotics as ordered. 4. Pt. adhered to treatment and stated the reason for antibiotic

medication therapy to prevent bacterial infection.

Evaluation of outcomes objectives:

Pt. met desired outcome of show no signs of developing a chronic infection. Pt. stated S&S of infection and
stated his understanding of how to prevent infection with the use of several treatments such as antibiotics and
constant monitoring.

Problem # _4__: Imbalanced Nutrition: Less than Body Requirements.

General Goal: Patient will maintain adequate nutritional intake and show little signs of
malnutrition.
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Predicted Behavioral Outcome Objective (s): The patient will……

Demonstrate adequate nutritional intake by eating breakfast, lunch, and dinner high in nutrients,
as well as several snacks and adequate fluid on the day of care.

Nursing Interventions Patient Responses

1. Encourage snack varieties. 1. Pt. chose desirable snacks to eat throughout day.

2. Monitor intake and output. 2. Pt. assisted in showing how much was ate and put out during

the day.

3. Provide high nutrient meals. 3. Pt. successfully ate 100% of all meals without complaints.

4. Teach importance of adequate nutrition. 4. Pt. understood need for meals to increase weight and

nutrition and understood malabsorption signs.

Evaluation of outcomes objectives:

Pt. met desired outcome of maintaining adequate nutritional intake throughout the day by eating several snacks
and by consuming 100% of all main course meals.

Problem # _5__: Activity Intolerance

General Goal: Patient will show improved activity tolerance without signs of respiratory
distress and fatigue.

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

Demonstrate different activities and movement without experiencing distress or fatigue on the
day of care.

Nursing Interventions Patient Responses

1. Teach importance of frequent moving. 1. Pt. stated ways to improve activity to clear secretions.

2. Offer ideas for pt. to stay active. 2. Pt. stated many likes and dislikes of activities he
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enjoys and created a new daily list for improvement.

3. Monitor SpO2 while pt. performs activity. 3. Pt. was able to maintain O2 above 94% with.

activity.

4. Teach importance of rest periods in between 4. Pt. stated signs of fatigue and allowed for rest and

movement. recovery.

Evaluation of outcomes objectives:

Pt. met desired outcome of performing different activities and movement without experiencing distress or
fatigue. Pt. make list of new activities to try and was willing to learn strategies to tolerate activity better.

Problem # _6__: Knowledge Deficit

General Goal: Patient will demonstrate understanding of treatment regimen and the disease
process.

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

Demonstrate improved knowledge on medications, treatments, signs and symptoms, and the
disease process related to cystic fibrosis on the day of care.

Nursing Interventions Patient Responses

1. Teach S&S of CF and infection. 1. Pt. listed warning signs of complications related to

CF.

2. Allow pt. to perform own aerosol treatment. 2. Pt. correctly performed aerosol treatment and stated

importance.

3. Provide information on CF and outcomes. 3. Pt. stated thoughts and knowledge on disease process

related to CF and the outcomes.

4. Demonstrate medication administration. 4. Pt. demonstrated correct use of medications and

provided feedback and questions.

Evaluation of outcomes objectives:

Pt. met the desired outcome of improving knowledge related to his diagnosis of CF. Pt. demonstrated
treatment regiments, asked useful questions, and provided feedback on his own knowledge of the outcome of
his disease.
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Problem # _7__: Patient anxiety and lack of coping strategy.

General Goal: Patient will demonstrate healthy and effective coping strategies relating to
diagnosis of cystic fibrosis.

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

Demonstrate ways to reduce anxiety about disease and provide different ways of coping on the
day of care.

Nursing Interventions Patient Responses

1. Provide outcomes related to disease process. 1. Pt. shows an understanding of the inevitable

outcome of his disease.

2. Teach therapeutic ways to manage anxiety. 2.Pt. performed activities such as meditation to help

reduce anxiety.

3. Provide information on support groups. 3. Pt. agreed to join several support groups and meet

with others with cystic fibrosis.

4. Listen to pt’s concerns and stressors. 4. Pt. was able to show effective coping and ease by

expressing feelings and thoughts on his disease.

Evaluation of outcomes objectives:

Pt. met desired outcome of showing ways to reduce anxiety and learn effective coping techniques. Pt. reduced
anxiety by learning activities such as yoga, meditation, and different distraction techniques.

Problem # _8__: Chronic Stomach Pain and Distension

General Goal: Patient will reduce signs of abdominal pain and distension with different
treatments.

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

Perform many techniques to reduce discomfort and vocalize need for medications during
moments of distress on day of care.
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Nursing Interventions Patient Responses

1. Provide pancreatic enzymes. 1. Pt. shows understanding for the need of daily

enzymes to help pancreatic function.

2. Provide distraction techniques during distress. 2. Pt. chose to watch a movie during stomach pain for

distraction.

3. Teach importance of adequate nutrition. 3. Pt. listed foods to aide in easier digestion.

4. Show difference between normal stool and 4. Pt. was able to differentiate whether their stool

stool that would indicate malabsorption. showed issues such as malabsorption and when they

should take action.

Evaluation of outcomes objectives:

Pt. met desired outcome of learning many techniques to reduce discomfort and vocalize need for medications.
Pt. was able to recognize signs of distress and recognized when they should take needed action to reduce risk
of further issues.