Kaitlin North
CONCEPT MAP
2. Ineffective airway
clearance r/t increased
mucus production
Supporting data:
Nonproductive cough
inspiratory and expiratory
wheezes
Diminished breath sounds
azithromycin 10mg loading
dose/ 5mg for 4days for
suspected lung infection
4. Knowledge deficit r/t
medication regimen
Supporting data:
Incorrect method of inhaler
use by patient
Parents let medication
expire without refilling it
Parents needed taught what
SpO2 reading meant
7. Parental anxiety r/t
hospitalization of child
Supporting data:
Mother never leaves
bedside
voices concern about
childs chest tightness
1
5. Ineffective health
1. Impaired gas exchange
maintenance r/t lack of
r\t bronchospasm
rescue inhaler
Supporting data:
Supporting data:
Chest tightness
Rescue inhaler not
SpO2 95%, HR 115, RR 24
available during asthma
History of SpO2 90% in
attack, not available during
ED
periods of physical activity
Albuterol 2 puffs Q4H
Family unaware of
Prednisone 24.6 mg BID
expiration date of inhaler
QVAR 40 mcg 2 puffs BID
3. Ineffective breathing
pattern r/t constriction of
bronchioles
Reason for Needing Health Care: Supporting data:
Asthma exacerbation SpO2 95%, HR 115, RR 24
Inspiratory and expiratory
Key assessments: wheezes, Diminished
Breath sounds, respiratory rate and effort, breath sounds
pulse oximetry, capillary refill, heart rate, HOB elevated
skin color Intermittent, nonproductive
cough
6. Activity intolerance r/t 8. Caregiver role strain
insufficient energy to r/t chronically ill child
complete daily activities Supporting data:
Supporting data: 2 siblings at home
Patient reports shortness of Mother takes care of
breath and chest tightness younger cousins
during physical activity Both parents work full time
Patient unable to complete
gym activities
Patient unable to play
tag/other running games
with siblings and cousins
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Problem #1: Impaired gas exchange r\t bronchospasm.

General Goal: Increase Sp02 to normal levels (93-100% in children) and maintain normal vital signs.

Predictable Behavioral Outcomes Objective(s): The patient will maintain a Sp02 reading of 93% or
better, heart rate of 70-110, respiratory rate of 16-22 on the day of care.

Nursing Interventions Patient Responses

1) Assess respiratory rate, depth, and effort, 1) Patient had unlabored respirations, no use of
including use of accessory muscles and abnormal accessory muscles, and respiratory rate of 24
breathing patterns. breaths/min.

2) Auscultate breath sounds for adventitious 2) Breath sounds diminished, inspiratory and
sounds. expiratory wheezes present on assessment.

3) Assess vital signs every 4 hours. 3) Vital signs on the day of care: SpO2 95%
(normal), HR 115 (slightly elevated), RR 24 (slightly
elevated).

4) Monitor for changes in mental status and 4) Patient was alert and oriented x4 and exhibited no
behavior, such as restlessness, agitation, changes in behavior during shift.
confusion, and extreme lethargy (late stages).

5) Assess skin, nail beds, and mucous membranes 5) Patient exhibited no signs of cyanosis (skin was
of the mouth for cyanosis (late sign). warm and pink, capillary refill was <2 seconds,
mucous membranes pink) during shift.

6) Elevate the head of the bed 30-45 to increase 6) Patient maintained upright position during shift.
lung expansion.

7) Assess the patients ability to cough up 7) Patient had a dry, nonproductive cough during
secretions. shift.
Evaluation of Outcome: Respiratory rate (24 bpm) and heart rate (115 bpm) were slightly elevated so goal
was not met.

Problem #2: Ineffective airway clearance r/t increased mucus production.

General Goal: Decrease secretions and open airway for patient to cough up excess secretions

Predictable Behavioral Outcomes Objective(s): The patient will maintain a clear, open airway AEB
normal breath sounds, normal respirations, and ability to cough up secretions and deep breathe on the day
of care.

Nursing Interventions Patient Responses

1) Assess respiratory rate, depth, and effort, 1) Patient had unlabored respirations, no use of
including use of accessory muscles and abnormal accessory muscles, and respiratory rate of 24
breathing patterns. breaths/min.

2) Auscultate breath sounds for adventitious 2) Breath sounds diminished, inspiratory and
sounds. expiratory wheezes present on assessment.

3) Assess the patients ability to cough up 3) Patient had a dry, nonproductive cough during
secretions. Note the color, consistency, amount, shift.
and odor of sputum coughed up.
Kaitlin North 3

4) Teach the patient how to cough and deep 4) Patient had a dry, nonproductive cough during
breathe (sit upright, take a deep breath, hold it, shift.
then cough 2-3 times in succession).

5) Administer QVAR 40 mcg 2 puffs BID to open 5) Patient tolerated inhaler and respiratory treatments
airway and azithromycin 10mg loading dose/ 5mg well (azithromycin was a nighttime medication).
for 4days and Prednisone 24.6 mg BID for
suspected lung infection (Respiratory therapy
administers Albuterol 2 puffs Q4H).

6) Encourage patient to increase fluid intake to 6) Patient had good oral fluid intake during shift and
minimize mucosal drying and maximize ability to did not require IV fluids during hospitalization.
move secretions.

7) Elevate the head of the bed 30-45 to increase 7) Patient maintained upright position during shift.
lung expansion.

8) Assess for temperature caused by inflammatory 8) Patients temperature was 36.7C/98.1F.

process/infection.
Evaluation of Outcome: Patient had a cough but was not bringing up secretions; wheezes were still
present during auscultation of breath sounds so goal was not met.

Problem #3: Ineffective breathing pattern r/t constriction of bronchioles

General Goal: maintain normal respiratory rate and be without dyspnea

Predictable Behavioral Outcomes Objective(s): The patient will maintain a respiratory rate of 16-22 and
have no episodes of dyspnea during physical activity on the day of care.

Nursing Interventions Patient Responses

1) Assess respiratory rate, depth, and effort, 1) Patient had unlabored respirations, no use of
including use of accessory muscles and abnormal accessory muscles, and respiratory rate of 24
breathing patterns every 4 hours. breaths/min.

2) Auscultate breath sounds for adventitious 2) Breath sounds diminished, inspiratory and
sounds. expiratory wheezes present on assessment.

3) Monitor pulse and oxygen saturation using 3) Patients SpO2 was 95%, heart rate was 115.
pulse oximetry.

4) Assess skin, nail beds, and mucous membranes 4) Patient exhibited no signs of cyanosis (skin was
of the mouth for cyanosis (late sign). warm and pink, capillary refill was <2 seconds,
mucous membranes pink) during shift.

5) Assess for chest pain or tightness. 5) Patient reported chest tightness at the end of the
shift.

6) Teach the patient how to use a peak flow meter 6) Patient was cooperative and willing to learn.
and record readings to manage their asthma
symptoms.

7) Elevate the head of the bed 30-45 to increase 7) Patient maintained upright position during shift.
lung expansion.

8) Ask patient and parents about precipitating 8) Patient reported difficulty breathing during and
factors to respiratory distress. after physical activity at school during gym class.
Kaitlin North 4

Evaluation of Outcome: Goal was not met due to respiratory rate being 24 (not within normal range of 16-
22) and patient report chest tightness.

Problem #4: Knowledge deficit r/t medication regimen.

General Goal: Teach correct method of medication use.

Predictable Behavioral Outcomes Objective(s): The patient will demonstrate the correct method for
inhaler use with spacer on the day of care.

Nursing Interventions Patient Responses

1) Assess intellectual abilities and willingness to 1) Patient cooperative and willing to learn.
learn before teaching.

2) Use visual aids to enhance learning. 2) Patient and patients mother paid special attention
to the handout given to them, which had pictures to
show how asthma affects the body.

3) Include the parents in the teaching. 3) Patients mother participated in the asthma
teaching, father was not visiting during the teaching.

4) Provide community resources to continue to
coordinate care after discharge.
4) Patients family provided with contact information
for local resources that focus on childhood asthma,
and the Akron Childrens Hospital Asthma Action
Plan to use at home to prevent flare-ups and decrease
hospitalizations.

5) Teach the patient how to use a peak flow meter 5) Patient cooperative and willing to learn.
and record readings to manage their asthma
symptoms.

6) Demonstrate the correct way to administer 6) Patient administered the second puff correctly
QVAR 40 mcg 2 puffs by showing them with the after being shown the correct method with the first
first puff, and then having them repeat the steps puff. Patient used a spacer due to inability to hold
with the second puff. breath for 10 seconds each administration.

Evaluation of Outcome: Patient met goal of demonstrating correct inhaler use and was cooperative and
attentive during the asthma teaching.

Problem #5: Ineffective health maintenance r/t lack of rescue inhaler

General Goal: increase knowledge about disease and treatments

Predictable Behavioral Outcomes Objective(s): The patient will identify reasons for needing the
medication on the day of care.

Nursing Interventions Patient Responses

1) Assess patient feelings and concerns about 1) Patient family reported not realizing that the
adhering to the treatment plan. medication expired.

2) Assess intellectual abilities and willingness to 2) The patient and family were open to learning
learn before teaching. about the medication and treatment plan.

3) Help the patient and family find a way to 3) Patient and family were provided with an Asthma
manage the medication schedule. Action Plan to detail information such as their
Kaitlin North 5

doctor, medications, triggers, and symptoms.

4) Provide community resources to continue to 4) Patients family provided with contact information
coordinate care after discharge. for local resources that focus on childhood asthma.

5) Teach the patient and family signs and 5) Patient identified difficulty with exercise,
symptoms that indicate the need for the rescue shortness of breath, and chest tightness as signs to
inhaler. use the rescue inhaler.

6) Teach the patient about triggers- things that 6) Patient identified exercise, pollen, and cold/flu as
cause asthma to flare up. triggers for their asthma.
Evaluation of Outcome: Goal was met- patient identified reasons for needing their medication and was
open to learning.

Problem #6: Activity intolerance r/t insufficient energy to complete daily activities
General Goal: increase tolerance to physical activity

Predictable Behavioral Outcomes Objective(s): The patient will show tolerance to physical activity
AEB decreased incidence of respiratory distress during activity on the day of care.

Nursing Interventions Patient Responses

1) Assess the patients nutritional status (energy is 1) Patient ate 75% of breakfast.
needed to complete activities).

2) Assess emotional response to the inability to 2) Patient reported being unable to participate during
complete activities. certain gym class activities, as well as being upset
with not being able to run and play with their siblings
and cousins.

3) Give the patient more time and periods of rest 3) Patient rested before and after going to the play
during activities. room.

4) Prioritize nursing care and give time between 4) Patient responded well to physical activity
planned exertion periods, such as treatments and associated with hygiene.
hygiene.

5) Assess patient response to physical activity and 5) Patient reported chest tightness between
respiratory treatments. respiratory treatments.

6) Provide diversion/play that does not require 6) Patient responded well to these activities and
high levels of activity (did a puzzle together, reported enjoying watching movies at home.
watched TV/movie).
Evaluation of Outcome: Goal was met- patient responded well to playing in the play room.

Problem #7: Parental anxiety r/t hospitalization of child

General Goal: Decrease parental anxiety.

Predictable Behavioral Outcomes Objective(s): Mother of the patient will have decreased anxiety on
the day of care AEB verbal expression of relief, decreased pacing, and increased relaxation.

Nursing Interventions Patient Responses

1) Allow parent to express concerns about childs 1) Parents anxiety decreased after asthma teaching.
Kaitlin North 6

hospitalization.

2) Allow parent to stay with child for assessments 2) Promoted parental participation in care of child.
and procedures.

3) Explain all procedures in simple, non-medical 3) Promoted parental knowledge about the disease
jargon. process and treatments provided to the child.

4) Use empathy to encourage the parent that 4) Provided emotional support to the parent.
anxiety is normal.

5) Assess social and emotional history of the 5) Provided information on strengths and weaknesses
patient and family for strengths and coping that could be used to cope with the childs
abilities. hospitalization.

6) Allow family to bring favorite things and 6) Provided security and familiarity in an unfamiliar
routines from home. environment to promote comfort.

Evaluation of Outcome: The goal was met- the parent had decreased anxiety during the shift.

Problem #8: Caregiver role strain r/t chronically ill child

General Goal: Identify positive coping strategies.

Predictable Behavioral Outcomes Objective(s): The mother of the patient will identify/demonstrate
positive coping strategies on the day of care.

Nursing Interventions Patient Responses

1) Allow parent to express feelings and concerns 1) Parents anxiety about their childs hospitalization
about childs illness. decreased.

2) Encourage the parent to take breaks and offer 2) Patients mother declined to leave the bedside.
to watch child while they are taking a break.

3) Provide diversional activities for the parents to 3) Parents watched TV and played games with their
decrease anxiety. child during hospitalization.

4) Encourage the parent to find time to meet their 4) Promoted respite for the parent to decrease stress.
needs.

5) Teach the parent how to provide care to the 5) Provided an Asthma Action Plan to coordinate
child at home, and put a plan in place to manage their medication schedule, doctor information, and
the care effectively. triggers to their asthma to be more prepared and
decrease stress by having a plan in place to follow.

6) Assess social and emotional history of the 6) Provided security and familiarity in an unfamiliar
patient and family for strengths and coping environment to promote comfort.
abilities.
Evaluation of Outcome: The goal was met due to the parents having decreased anxiety and increased
ability to cope with the stress of caring for a chronically ill child.