1

Key Problem
Ineffective Airway
Clearance
* 5 months old with little
Key Problem airways already Key Problem
Ineffective Breathing * Moderate amounts of Risk for Dehydration
Pattern thick white secretion * Excessively crying
* Using accessory muscles buildup * Not able to drink fluids
to breathe * Has inflamed bronchioles on command like with
* Has subcostal retractions * Has diminished breath older children
* Swollen bronchioles sounds * Dry mucus membranes
* SpO2 95% * SpO2 95% from nasal cannula
* Breathing treatments into
mouth causing dryness

Key Problem
Ineffective Coping
*5 months
*Does not have capacity to
properly cope due to age
*Excessively screaming
and crying
Key Problem
Risk for Agitation
* Crying a lot
* HR 118
* Difficulty breathing
causing strain on the body
Key Problem
Reason For Needing Health Care Fatigue
Patient (5-month-old male) presented in * Using accessory muscles
the ER with tachypnea and subcostal to help breathe
retractions and has been diagnosed with * Having to use more
RSV energy from his body
Key Assessments: * 5 months old
Auscultate often * Excessively crying
Suction amount
SpO2
Retractions
Heart rate
Respiratory rate
Section amounts
Key Problem
Airway patency
Risk for Impaired Gas
Exchange
* Has swollen bronchioles
making it difficult to bring
in O2
Key Problem * Has moderate amounts of
Risk for Complications thick white secretions
from Infection * Small size in bronchioles
* Positive for RSV due to age
* Has an immature immune * SpO2 95%
system (5mos)
* Patient is around different
individuals
* Hospital setting

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # ________4________:
General Goal: Patient will have an improved respiratory status with an increase in SpO2

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

demonstrate improved gas exchange

on the day of care.

Nursing Interventions Patient Responses

1. Apply O2 1. SpO2 went up from 95% to 97%

2. Suction often 2. Patient is not coughing as often
3. Hydrate patient 3. More secretions loosened up
4. Auscultate breath sounds 4. Patient is not wheezing as bad
5. Watch for retractions 5. Patient is not retracting as severely with O2
6. Maintain airway by elevating
head 6. Not struggling to breathe as much
7. Promote comfort 7. Patient is noy as agitated and is breathing better
8. Provide humidifier 8. Patient is putting out more secretions

Evaluation of outcomes objectives:

Patient demonstrated a better respiratory status with little to no retractions and an increase of SpO2 status.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # _________6________:
General Goal: Patient will have decreased agitation and parents will have decreased anxiety
Predicted Behavioral Outcome Objective (s): The patient will……
Show signs of decreased anxiety with less crying and agitation with signs from the parents
that they are less anxious
on the day of care.
Nursing Interventions Patient Responses

1. encourage parents to stay with 1. Patient seemed calmer when parents were
the patient present
2. Give patient distractions like 2. Patient was distracted and did not seem agitated
a mobile to hang when mobile was running
3. Teach parents about disease 3. Parents knew what to expect so they were not as
process anxious
4. Let parents take small breaks 4. Parents were able to refresh their minds

5. Explain reasoning for oxygen 5. Parents were able to understand there was no
harm being done to the child, and it was
increasing his SpO2
6. Apply oxygen to ease patient’s 6. Patient was less agitated when he was able to
respirations breathe better

7. Reward patient after treatments 7. Patient seemed intrigued in rattle given after
with toys treatments
8. Assess level of anxiety from parents 8. Was able to determine parents were a little
anxious, especially because of the baby’s age, and I was able to determine methods to
relieve anxiety

Evaluation of outcomes objectives:

Parents were less anxious about treatments and what the patient was experiencing and how we were helping
him. The patient was less agitated when given respiratory relief and distractions.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # ___1____:
General Goal: Patient will have a more patent airway.

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

Show signs of a more patent airway with treatments
on the day of care.

Nursing Interventions Patient Responses

1. Humidifier 1. Loosened secretions

2. Suction often 2. Removed secretions to clear airway
3. Hydrate with Pedialyte 3. Kept body hydrated from suctioning, gave
and formula relief from coughing, and loosened secretions
4. Keep head elevated 4. Allowed secretions to come up easier and
prevented them from sliding down more
Evaluation of outcomes objectives: Patient expelled more secretions and seemed to have more ease when
breathing.

Problem # ______2___________:
General Goal: Patient will overall be as hydrated as possible.

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

Show signs of good hydration
on the day of care.

Nursing Interventions Patient Responses

1. Pedialyte 1. Patient seemed in better spirits

2. IV fluids 2. Patient urinated more often
3. Took formula 3. Gained nutrients and fluids in one
4. Applied moisturizer to skin 4. Patient’s skin absorbed moisturizer and
rehydrated skin

Evaluation of outcomes objectives:

Patient showed signs of rehydration through skin turgor and skin moisture.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # ______3___________:
General Goal: Patient will show signs of increasing energy.

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

Have an increase in energy
on the day of care.

Nursing Interventions Patient Responses

1. Give toys to patient to
decrease crying and agitation
2. Patient will get more rest
3. Give oxygen
4. Give nutrients like formula
1. Patient was in better spirits and was less agitated
2. Patient got more energy from rest periods
3. Oxygenation eased respirations and eased
breathing
4. Nutrients gave more energy

Evaluation of outcomes objectives:

Patient showed an increase in energy and was in better spirits.

Problem # ______7___________:
General Goal: Patient will demonstrate a more at ease breathing pattern.

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

Will display a more at ease respiratory effort on the day of care.

Nursing Interventions Patient Responses

1. Give oxygen 1. Patient’s SpO2 went from 95% to 97%

2. Suction secretions 2. Patient brings more oxygen in with less
Secretions blocking airway
3. Hydrate with Pedialyte 3. Loosened secretions to excrete
4. Maintain airway elevate HOB 4. Patient showed breathing was at ease

Evaluation of outcomes objectives:

Patient showed an adequate breathing pattern appropriate for disease.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # ______5___________:
General Goal: Patient’s will not get a more severe infection than RSV.

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

Not exhibit signs of further infection on the day of care.

Nursing Interventions Patient Responses

1. Limit visitors 1. Encourage only parents in room

2. Wear PPE 2. Prevented bringing in more hospital germs to
patient
3. Make sure bottle nipples are clean 3. Prevented spread of germs into mouth
4. Hand hygiene 4. Prevents skin to skin contact spread

Evaluation of outcomes objectives:

Patient showed no signs of furthering infection.

Problem # ______8___________:
General Goal: Patient’s will not get a more severe infection than RSV.

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

Not exhibit signs of further infection on the day of care.

Nursing Interventions Patient Responses

1. Limit visitors 1. Encourage only parents in room

2. Wear PPE 2. Prevented bringing in more hospital germs to
patient
3. Make sure bottle nipples are clean 3. Prevented spread of germs into mouth
4. Hand hygiene 4. Prevents skin to skin contact spread

Evaluation of outcomes objectives:

Patient showed no signs of furthering infection.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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Problem # ______7___________:
General Goal: Patient and parents will demonstrate effective coping

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

Exhibit an ease in behavior and parents will show appropriate coping mechanisms
on the day of care.

Nursing Interventions Patient Responses

1. Sit with parents when needed 1. Gave parents time to talk with me
2. Provide adequate nutrition and hydration 2. Adequate nutrition and hydration
seemed to make the patient behave better
patient
3. Let parents talk with other parents 3. Parent talking with other parents gave a
sense of support
4. Gave patient toy from home 4. Toy from home gave sense of comfort

Evaluation of outcomes objectives:

Patient and parents both showed effective coping mechanisms that were age appropriate.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis