Michaela Watkins
CONCEPT MAP
Key Problem Key Problem Key Problem
Ineffective airway clearance Fatigue Deficient knowledge
(caregiver)
Supporting data: Supporting data:
Nasal congestion, non- Not sleeping well, Supporting data:
productive cough, bronchial increased respiratory Tylenol use, disease process,
inflammation and effort, irritable, fussy, contact/droplet isolation,
obstruction in small airways poor nutrition when to see medical help
Key Problem
Key Problem Reason For Needing Health Care Risk for dehydration
Risk for aspiration Respiratory distress due to bronchiolitis
Supporting data:
Supporting data: Key assessments: Irritability/restlessness,
Persistent cough, oxygen Lung sounds, vital signs, respiratory strict I&O, poor skin
saturation 91%, bronchial effort and rate, pulse oximetry, capillary turgor, increased capillary
obstruction refill, skin color, use of accessory refill
muscles, retractions, head bobbing,
nasal flaring, intake and output, and
nutritional needs
n
Key Problem Key Problem
Ineffective breathing pattern Impaired comfort
Key Problem
Supporting data: Caregiver role strain Supporting data:
Respirations 36, heart rate 37.6 Celsius temperature,
130, oxygen saturation 91%, Supporting data: fussy when touched, Tylenol
bilateral expiratory wheezes, Grandmother is sole provider, 160 mg q6 PRN
intercostal retractions, nasal mom/dad have legal issues, stays
flaring, use of accessory at bedside
muscles, pale skin, positive
rhinovirus and enterovirus
Michaela Watkins
Evaluation of Outcomes
Problem 1: Ineffective airway clearance
General Goal: Avoid dyspnea and cyanosis
Predicted Behavioral Outcome Objective (s):
The patient will display clear lungs sounds and effective coughing on the day of care.
Nursing Interventions Patient Responses
1. Assess lung sounds 1. Wheezing is improving and not as severe
2. Assess cough 2. Cough is clear with no mucous production
3. Monitor respiratory status 3. Respiratory pattern is regular with mild retractions
4. Elevate HOB and respirations are 36
4. Child sitting in upright position
Evaluation of outcomes objectives:
Patient showed no signs of dyspnea, and cyanosis it not present. Goal was met.
Problem 2: Fatigue
General Goal: Show no S/S of severe tiredness
Predicted Behavioral Outcome Objective (s):
The patient will be able to eat, drink, and play on day of care.
Nursing Interventions Patient Responses
1. Schedule periods of rest 1. Child has specific times where rest was encouraged
2. Assess amount of sleep 2. Child was able to take midday nap for an hour
3. Cluster care as best as possible 3. Minimizing the number of times I enter the room allows child
to rest longer.
4. Provide a quiet, comfortable 4. Patient able to rest peacefully.
environment.
Evaluation of outcomes objectives:
Patient was able to rest, which allowed for efficient eating and drink as well as periods of
play time. Goal was met.
Michaela Watkins
Problem 3: Deficient knowledge (Caregiver)
General Goal: Caregiver will have knowledge regarding child’s disease
Predicted Behavioral Outcome Objective (s):
The caregiver will be able to understand the disease process, methods of prevention, and
treatment on day of care.
Nursing Interventions Patient Responses
1. Assess preexisting knowledge. 1. Caregiver baseline knowledge is little
2. Teach S/S of respiratory distress 2. Caregiver able to recite common S/S
3. Medication administration 3. Caregiver understands medications are mg/kg
4. Teach prevention of spread 4. Caregiver understands the isolation protocol
Evaluation of outcomes objectives:
Caregiver was able to understand bronchiolitis and how to prevent and assess for it. Goal was
met.
Problem 4: Ineffective Breathing Pattern
General Goal: Patient will maintain normal rate of breathing
Predicted Behavioral Outcome Objective (s):
Patient will show relaxed breathing at a normal rate with absence of dyspnea on day of
care.
Nursing Interventions Patient Responses
1. Assess pulse rate and O2 sat 1. Pulse is 130 and SpO2 is 91%
2. Provide cool mist humidifier 2. Patient showed decrease work of breathing
3. Assess lung sounds 3. Wheezing is improving
4. Note for change in LOC 4. No change in LOC
Evaluation of outcomes objectives:
Patient demonstrated relaxed breathing and shows no dyspnea. Goal was met.
Michaela Watkins
Problem 5: Risk for aspiration
General Goal: Patient will not aspirate and show clear lung sounds
Predicted Behavioral Outcome Objective (s):
Patient will present clear lungs sounds, unlabored breathing, and normal oxygen saturation
on day of care.
Nursing Interventions Patient Responses
1. Keep suction at bedside 1. Safety check per policy explained to caregiver
2. Assess SpO2 and lung sounds 2. SpO2 at 91% and mild expiratory wheezes present
3. Elevate HOB 3. Child sitting in upright position
4. Teach caregiver to monitor S/S. 4. Caregiver aware of the risk for aspiration and when to report
Evaluation of outcomes objectives:
Patient presented with adequate SpO2, lung sounds are improving, and no aspiration
occurred. Goal was met
Problem 6: Risk for Dehydration
General Goal: Encourage fluid intake and avoid dehydration
Predicted Behavioral Outcome Objective (s):
Patient will reach fluid requirement based on weight on day of care.
Nursing Interventions Patient Responses
1. Monitor intake and output 1. Output did not exceed input
2. Assess hydration status 2. Capillary refill <3 seconds and good skin turgor
3. Encourage PO fluids 3. Pedialyte and formula consumed on shift
4. Monitor electrolytes 4. Electrolytes within normal limits
Evaluation of outcomes objectives:
Patient achieved weight- based fluid requirement on shift and maintained hydration status.
Goal was met.
Michaela Watkins
Problem 7: Caregiver role strain
General Goal: Caregiver will understand that staff is here to help and maintain proper
health within self.
Predicted Behavioral Outcome Objective (s):
Caregiver will rest and take breaks as needed on day of care.
Nursing Interventions Patient Responses
1. Allow caregiver to step out PRN 1. Caregiver able to take breaks to eat, etc.
2. Provide stress-reduction methods 2. Caregiver is able handle stress of having child in hospital
3. Offer support 3. Caregiver accepts and feels supported by staff
4. Allow caregiver to discuss feelings 4. Caregiver able to share concerns
Evaluation of outcomes objectives:
Caregiver was able to discuss any concerns and take breaks when needed. Goal was met.
Problem 8: Impaired comfort
General Goal: Patient will feel comfortable
Predicted Behavioral Outcome Objective (s):
Patient will present no fever or pain and demonstrate ability to rest in hospital on day of
care.
Nursing Interventions Patient Responses
1. Assess temperature 1. Temperature (temporal) reading is 37.6 Celsius
2. Assess pain via FLACC scale 2. FLACC scale at 0
3. Assess ability to rest adequately 3. Child able to rest for up to an hour with no disturbance
4. Tylenol 160 mg q6 hour PRN 4. Tylenol no needed based on assessment findings
Evaluation of outcomes objectives:
Patient has no fever or pain and was able to feel comfortable. Goal was met.
