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Conor Crogan

Concept Map

#6 Parental Anxiety
#1 Impaired Gas Exchange
R/T R/T
#3 Risk for Infection
-suprasternal and -parent crying at
intercostal retractions R/T bedside when their
-heart rate of 153 -isolation child was crying
(tachycardia) -increased -parent not leaving
-pale bedside
-family history of asthma secretions
-parent asking a lot of
- Pulse Oximeter reading questions

#8 Ineffective Breathing Reason for Needing Health Care: Risk for ineffective
#7
Pattern Bronchiolitis
4 Y.O.
airway clearance
R/T
-inflammatory process
R/T
- tracheobronchial Key Assessments: -tracheobronchial
-lung sounds obstruction
obstruction -vital signs: RR, HR, BP, temperature
-increased work for -pulse oximeter -secretions
breathing -capillary refill -infection
-skin color

#2 Risk for Dehydration

#5 Risk for Impaired Comfort #4
R/T Disturbed Sleep Pattern R/T
-coughing R/T -poot intake of fluids
-constant assessments done -administration of -poor urinary output
on child/constant - Coughing
albuterol every 3 hours
interruptions
-increased mucus and -increased mucous - increased resp. rate
secretions in nose and throat production and secretions
- Patient fussy/crying -coughing
-constant assessments done on
child/constant interruptions
-increased mucus and
secretions in nose and throat

Problem # ___1____: Impaired Gas Exchange

General Goal: Patient maintains clear lung fields and remains free of signs of respiratory distress
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Predicted Behavioral Outcome Objective (s): The patient will…… verbalizes understanding of
oxygen and other therapeutic interventions or parents will on the day of care.

Nursing Interventions Patient Responses

1. Position patient with head of the 1. Maintain clear airway, easy to breath
bed elevated
2. Encourage slow deep breathing  2. Use incentive spirometry to stabilize lungs
3. Regularly check the patient’s 3.Patient will maintain proper posture in bed.
position so that they do not slump down
4. Encourage ambulation as per the 4.Patient will do little activities with nurse or parents.
physician’s order.

Evaluation of outcomes objectives: Patient was able to keep gas exchange WDL during shift by carrying out
these interventions and actions.

Problem # __2__: Risk for Dehydration

General Goal: Patient will drink water throughout the day.

Predicted Behavioral Outcome Objective (s): The patient will… maintain the adequate amount
of fluid for age and weight on the day of care.

Nursing Interventions Patient Responses

1. Urge the patient to drink the 1. Patient will drink fluids when told to
prescribed amount of fluid.
2. Emphasize oral hygiene 2. Patient will use mouthwash and toothpaste
3. Encourage family to help eat 3. Family will make it easier for child to drink
and drink fluid on time.
4. Make sure IV is patent 4. Patient will keep iv site clean and accessible
in case of emergency
Evaluation of outcomes objectives: Patient was able to use interventions and maintain adequate fluid and
electrolyte balance

Problem # ___3____: Risk for Infection

General Goal: Client will remain free of infection
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Predicted Behavioral Outcome Objective (s): The patient will…… maintain normal vital signs
and absence of signs and symptoms of infection on the day of care.

Nursing Interventions Patient Responses

1. Nurse will wash hands before
and after contact with patient
2. Educate client on proper hand
hygiene
3. Encourage balanced diet
3. Encourage coughing and deep
breathing exercises
1. Patient will maintain good hand hygiene.
2. Parents will help patient stay clean
3. Will keep body healthy by eating a nutritious
meal
4. Patient will cough when told to or needed and change
positions when told to.

Evaluation of outcomes objectives: Patients vitals were normal throughout the day and CBC came back with
normal lab values for infection clearance.

Problem # _______4__________: Disturbed Sleep Pattern

General Goal: Patient obtains optimal sleep

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

periods and will verbalization of feeling rested, and improvement in sleep
pattern on the day of care.

Nursing Interventions Patient Responses

1. Educate on proper fluid and 1. Avoid heavy meals, coffee, tea. sugars
food intake .
2. Encourage patient to drink 2. Promotes sleep
milk
3. Create sleep schedule with 3. Will follow sleep schedule
patient
4. Inform patient to not drink 4. Patient wont wake up to pee in the night
a lot of fluids before bed
Evaluation of outcomes objectives: Patient slept well and took naps throughout the day, patient stated that they
were not tired and were well rested.

Problem # 5: Risk for impaired comfort

General Goal: Pt will get comfortable to help get rest
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Predicted Behavioral Outcome Objective (s): The patient will…… increase

fluids to promote thinning of secretions to allow for better comfort when lying
down by the end of my shift.
Nursing Interventions Patient Responses

1. Listen to lungs 1. Lungs were a little coarse but didn’t get worse
2. Encourage fluids 2. Pt would take sips of water when asked
3. Encourage coughing 3. Pt will cough when instructed to do so
4. Encourage rest 4. Pt will limit activities and nap daily

Evaluation of outcomes objectives:

Goal was met. Pt was able to get a lot of rest while I was there. He did everything we asked to help
promote better rest

Problem # 6: Parental anxiety

General Goal: Parent’s anxiety will decrease.

Predicted Behavioral Outcome Objective (s): The parents will… continue to get
better so the parent’s anxiety decreases by the end of my shift or discharge.

Nursing Interventions Patient Responses

1. Tell the parents how amazing 1. The parents are feeling less stressed
they are coping and patient care
2. Offer the parents coffee, water, 2. Parents enjoyed the coffee
etc.
3. Answer any questions they have 3. Parent’s felt better after asking questions
4. Encourage the parents to vent 4. They thanked me for being there to talk to them
5. Encourage parents to cuddle 5. Parents seemed a lot calmer when holding him
and hold their child
Evaluation of outcomes objectives:

Goal was met. By the end of my day there, the parents had a calmer look on their faces and
repeatedly thanked me for all the help I provided to their son and to them.

Problem # ___7____: Risk for Ineffective Airway Clearance

General Goal: Patient will maintain clear, open, airways.
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Predicted Behavioral Outcome Objective (s): The patient will…… have normal breath sounds
normal rate and depth of respirations, and ability to effectively cough up secretions after
treatments and deep breaths by end of shift.

Nursing Interventions Patient Responses

1. Teach the patient the proper ways
of coughing and breathing.
2. Educate patient of the use of
abdominal muscles for forceful cough
3. Have patient position upright
4. Use Incentive Spirometry
1. Take deep breaths, hold for 2 seconds
2. Control forceful cough to get all secretions.
3. Position promotes better lung expansion
4. Promote lung expansion, mobilize secretions
with incentive spirometry.

Evaluation of outcomes objectives: Patient was able to keep airway clear and improve lung expansion with
exercises like incentive spirometry and forceful cough treatments.

Problem # __8__: Ineffective Breathing Pattern

General Goal: Patient’s respiratory rate remains within established limits during shift.

Predicted Behavioral Outcome Objective (s): The patient will… maintain patients proper body
alignment for maximum breathing.

on the day of care.

Nursing Interventions Patient Responses

1. Maintain clear airway 1. Prevent aspiration by clear airway

2. Inspiratory Training 2. Patient will train to strengthen lungs
3. Encourage rest 3. Patient will rest and limit physical activities
4. Encourage cough 4.Patient will couch when needed

 Evaluation of outcomes objectives: Patient maintains an effective breathing pattern, as

evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.