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Paris Bumgardner

Concept Map

Fluid volume deficit

#1 Risk for Supporting data:
constipation #2 -Post operation condition
Supporting data: -Edema stemming from stoma
-Hypoactive bowel -Poor intake post-op
sounds -Frequent enema use for stoma
-Lack of nerve
inner action to
bowel
-Dehydration Risk for impaired
-Hard stool Reason for Needing Health Care: skin integrity
#3
Hirschsprung’s Disease Supporting data:
-Stoma irritation
Key Assessments: -Limited mobility
-Abdominal assessment post-op
-Vital signs -Mild skin
-Bowel / stool assessment
-Surgical site assessment
breakdown near
-Intake and Output stoma
-Poor intake
#4
#5
Knowledge deficiency
Risk for Infection
Supporting data:
Supporting data:
-Learning deficit about
-Recent ostomy
stoma
placement
-Stoma care
-Malone stoma
-Enemas through
-Low WBC count
Malone stoma
-
-SCD use
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Problem # 1: Risk for constipation

General Goal: Patient/family will determine measures to prevent constipation

Predicted Behavioral Outcome Objective (s): The patient will teach back measures to prevent
constipation

Nursing Interventions Patient Responses

1. Encourage patient to increase fluid 1. Patient was improved on intake from

1. Show
intake as tolerated previous day
2. Encourage patient to take the 2. Patient was able to finish high fiber
provided dietary supplements breakfast (liquid)
3. Use enema in stoma as needed 3. Patient is learning how to properly use
4. Teach patient to use the enema the enema
4. Patient was able to show nurse how to
administer

Evaluation of outcomes objectives: Patient and family learned more about the non pharmaceutical
was to deal with constipation.

Problem # 2: Fluid volume deficit

General Goal: Patient will increase fluid intake throughout the day

Predicted Behavioral Outcome Objective (s): The patient will consume the appropriate amount
of fluids for his age and weight.

Nursing Interventions Patient Responses

1. Record accurate I&O’s and have 1. Patient is improving on fluid intake

patient replace fluids lost
2. Assess color and amount of urine
3. Monitor serum electrolytes
4. Weigh daily with the same scale
2. Patient is demonstrating successful use
of the urinal
3. Patient is fearful of needles but family
support helps him a great deal.
4. Patient is compliant with the daily
weights and likes to guess his weight

Evaluation of outcomes objectives: Serum electrolyte were mildly off balance but are improving with the also
improving intake.
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Problem # 3: Risk for impaired skin integrity

General Goal: Patient obtains clean dry and intact skin

Predicted Behavioral Outcome Objective (s): Patient will learn how to properly cleanse stoma
and have good overall skin care.
help of mother and keep skin clean dry and intact

Nursing Interventions Patient Responses

1. 1. Teach how to clean stoma site 1. Patient had a learning curve with this one
2. Teach patient to clean any stool due to the dislike of appearance. Family
that may get on the skin demonstrated an understanding.
3. Monitor skin color and skin 2. Patient was understanding of the teaching
irritation 3. Patient and family demonstrated an
4. Keep skin clean dry and understanding of assessing his own skin
moisturized 4. Patients skin looks clean and moisturized
except the mild redness around stoma,
which is being addressed.
Evaluation of outcomes objectives: Patients skin was mildly irritated but showed signs of improvement.
Patient and family demonstrated an understanding on cleansing the stoma site.

Problem # 4: Risk for Infection

General Goal: Patient will remission free of infection

Predicted Behavioral Outcome Objective (s): Patient will maintain normal vital signs and remain
free from any other signs and symptoms of infection.

Nursing Interventions Patient Responses

1. Maintain proper hand hygiene prior to 1. Patient and nurse keep hands clean
entering and exiting the patient to fight any germs
rooms. 2. WBC count is currently slightly low
2. Assess WBC count but no signs of infection are
3. Educate patient/family on importance currently present.
of having good hand hygiene when 3. Patient/family will demonstrate hand
cleaning stoma site hygiene prior to stoma care
4. Assisting patient in keeping stoma 4. Patient was thankful for the
clean assistance

Evaluation of outcomes objectives: Patients vital signs remained normal and the WBC still show slightly
below normal.