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Mary Jo Wardle

Kimber Zolnier

Concept Map

Key Problem #2 Deficient Key Problem #3 Caregiver Key Problem #4 Impaired

Fluid Volume role strain skin integrity
Weight loss Calling off work Fluid deficit
Dry mucous membranes Caregiver reluctant to go Mucus membranes dry
Poor skin turgor home to eat/shower/get Nutritional deficits due to
Urine output clean clothes congestion
Weak cry Voices concerns Diaper rash
Increased RR/HR

Key Problem
Key Problem #1 Ineffective Reason For Needing Health Care
airway clearance Bronchiolitis-RSV +
Oxygen therapy I&O
SPO2 <93% Daily weight
Coughing IV site assessment
Need for nasal suctioning Temp, HR, RR, BP, SPO2
Retractions/nasal flaring Capillary refill
Pale Drainage/mucus/cough assessment
Head bobbing
Diminished lung sounds
HOB elevated
Increased RR
Key Problem Key Problem

Key Problem

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Problem # __1__: Ineffective airway clearance

General Goal: Adequate tissue perfusion

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

The patient will maintain SPO2 saturation of >92% on the day of care.
on the day of care.
Nursing Interventions Patient Responses

1. Nasal Suctioning 1. Patient tolerates suctioning well

2. Maintain oxygen therapy 2. SPO2 levels remain stable
3. Assess RR 3. RR will not go above 30/minute
4. Assess capillary refill 4. Capillary refill will be less than 3 seconds
5. Monitor lab work 5. Blood gases should be normal
6. 6.
7. 7.
8. 8.

Evaluation of outcomes objectives: Pt. maintained SPO2 >92% on day of care.

Problem # _2_: Deficient fluid volume

General Goal: Normal fluid volume

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

Patient will maintain normal I&O and vital signs on day of care.
on the day of care.
Nursing Interventions Patient Responses

1. Assess mucous membranes 1. Mucous membranes are pink and moist

2. Measure I&O 2. Input 80 cc output 2 diapers weighing 85 total
3. Monitor labs 3. Electrolytes WDL
4. Assess IV 4. IV rate of 10 mL/hr., clean/dry/intact/infusing
5. Monitor skin turgor 5. Skin does not tent
6. Monitor vital signs 6. All vital signs WDL
7. Weigh patient 7. Pt. has gained 6 oz. since admission
8. 8.

Evaluation of outcomes objectives: Pt. maintained I&O in normal range and vitals signs remained normal on
day of care.

Problem # __3__: Caregiver role strain

General Goal: Caregiver will take part in self-care activities.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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

Caregiver will take part in self-care activities to maintain psychological/emotional health on the
day of care.
on the day of care.
Nursing Interventions Patient Responses

1. Identify caregivers support 1. Support system includes father and grandma

2. Offer to stay with pt. 2. Caregiver went to café to get dinner.
3. Offer hygiene resources 3. Caregiver said she would rather go home
4. Encourage expression of feelings
4. Caregiver talked to me for a bit then her husband 5. Assist mother with care of pt.
5. Assisted mother with diaper changes
6. 6.
7. 7.
8. 8.

Evaluation of outcomes objectives: Pts. Caregiver maintained physical health and is improving
psychological/emotional help.

Problem # __4___: Impaired skin integrity

General Goal: Maintain skin integrity

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

The patient will maintain intact skin while on the day of care.
on the day of care.
Nursing Interventions Patient Responses

1. Assess skin 1. Document healthy skin in chart

2. Monitor pts. diaper 2. Change diapers frequently to prevent breakdown
3. Apply diaper cream as ordered 3. Peri area has a barrier to protect skin
4. Monitor IV site 4. No evidence of phlebitis/infiltration
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcomes objectives:

Pts. Caregiver demonstrated understanding of importance of maintaining skin integrity.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.