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Concept Map

Nutrition Less than Body Requirements Risk for Fluid Volume Deficit
Fatigue No IV fluids
Weight loss Lack of oral intake
Meal intake < 25% Dry mucus membranes
Loss of appetite Nausea and vomiting
Hyperactive bowel sounds
Blood sugar < 40
Reason For Needing Health Care:
Appendicitis/Appendectomy

Key Assessments
RLQ Pain
Incision Site
Abdominal Distension
Bowel Sounds
Bowel Patterns
GI upset
Nutrition
Heart rate/Temperature
Mucus Membranes
Skin Turgor

Risk for Infection Acute Pain Risk for Dysfunctional Gastrointestinal Motility
Post-op appendectomy Facial grimacing Immobilization
Immunosuppressed Verbal reports of pain on 0-10 scale Activity intolerance
Elevated heart rate and temperature Changes in eating patterns Lack of oral intake
Elevated WBCs Altered sleep patterns Abdominal pain
No antibiotic therapy Guarding RLQ GI distress
Immobilization

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

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Problem #1: Nutrition Less than Body Requirements

General Goal: Improve nutritional intake

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

Consume at least >75% of all meals and continue to advance diet on the day of care.

Nursing Interventions Patient Responses

1. Provide oral nutrition supplements 1. Pt drank Ensure protein drink

2. Provide designated meal schedule 2. Pt eating at same times QD
3. Provide bulk/high protein diet 3. Pt compliant with eating bulk foods
such as rice with chicken.
4. Enforce food diary 4. Pt will document all meals while preparing
for discharge
5. QD weights 5. Pt remains between 50-70 weight percentile
Evaluation of outcomes objectives:
Pt is improving nutritional intake as a result of decreased GI upset and pain, along with methods encouraging
focused mealtime.

Problem #2: Risk for Fluid Volume Deficit

General Goal: Maintain adequate hydration

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

Consume 100ml/hr or 2400ml/QD oral intake per fluid requirement based on weight in kg on the
day of care.

Nursing Interventions Patient Responses

1. Encourage fluids 1. Pt tolerating fluid consumption

2. Monitor strict I & O 2. Pt urinated in toilet specimen hat to measure
and record output
3. Monitor Electrolytes 3. Pt drinking Pedialyte and Gatorade
4. Monitor mucus membranes 4. Pt completed oral hygiene as a result of dry
mucus membranes cause a sticky mouth.
5. Admin isotonic fluids if
fluid requirement goal
cannot be met orally. 5. Pt did not need 0.9% NS administered due to
compliance with adequate oral intake.
Evaluation of outcomes objectives:
Pt met 2400ml/QD fluid requirement with various liquids such as jello, Gatorade, water, pedalyte, soup, etc.
with a decrease in concern for risk for fluid volume deficit upon discharge.

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

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Problem #3: Risk for Infection

General Goal: Free of Infection

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

Remain free of infection and be educated on signs of infection on the day of care.

Nursing Interventions Patient Responses

1. Monitor for inflammation at incision site 1. Pt aware of inflammation being a

sign of infection.
2. QD dressing changes 2. Pt understands importance of
keeping wound sterile.
3. Admin Tylenol for temp >99.5F 3. Pt’s temp remains < 98.6F
4. Monitor site for purulent drainage 4. Pt aware of colored drainage with
odor is a sign of infection
5. Aseptic technique and standard precautions 5. Pt demonstrates proper
hand hygiene

Evaluation of outcomes objectives:

Pt remains free of infection, demonstrates proper knowledge on signs of infection, and educated on how to
prevent infection.

Problem #4: Acute Pain

General Goal: Control pain

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

Rate RLQ pain < 5 and determine methods to prevent pain exacerbations on the day of care.

Nursing Interventions Patient Responses

1. Admin Ibuprofen 400mg Q6H 1. Pt verbalizes reduced pain after Ibuprofen

administration
2. Reposition – High Fowler’s 2. Pt comfortable/reduced tension to abdomen
3. Apply pillow over abdomen 3. Pt understands usage of firm pressure before
moving or coughing to reduce incision site strain
4. Provide distraction 4. Pt verbalizes pain rated a 3 while watching
a movie.
5. Provide emotional support 5. Pt feels comfort with mom at bedside
Evaluation of outcomes objectives:
Pt understands how to prevent pain onset with around the clock pain med administration and acknowledges
non-pharmalogical methods to decrease pain occurrence and severity.

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

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Problem #5: Risk for Dysfunctional Gastrointestinal Motility

General Goal: Sustain routine bowel patterns

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

Be free of GI distress such as nausea, vomiting, and constipation on the day of care.

Nursing Interventions Patient Responses

1. Monitor I & O 1. Pt understands importance of increasing fluids

to stimulate bowel motility.
2. Admin glycolax 2. Pt compliant with drinking glycolax and
understands the importance of pairing with
increased fluid intake.
3. Encourage ambulation 3. Pt ambulated in hall for 30 mins
4. High fiber diet 4. Pt compliant with progressing diet
5. Prevent stress stimulants 5. Pt compliant with avoiding foods that could
worsen vomiting or constipation.

Evaluation of outcomes objectives:

Pt did not experience nausea or vomiting episodes and was compliant with interventions to stimulate a bowel
movement.

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