This clinical concept map summarizes a 10-month-old patient's diagnoses, risks, interventions, and outcomes related to a bowel obstruction and recent surgery. The patient was at risk for infection due to incisions and tubes but remained infection-free. Nutrition was addressed with TPN and monitoring of glucose and electrolytes. Pain was assessed and the patient showed no signs of pain. The family was supported through the interrupted illness process and caregiver education focused on signs, nutrition, and infection prevention.
This clinical concept map summarizes a 10-month-old patient's diagnoses, risks, interventions, and outcomes related to a bowel obstruction and recent surgery. The patient was at risk for infection due to incisions and tubes but remained infection-free. Nutrition was addressed with TPN and monitoring of glucose and electrolytes. Pain was assessed and the patient showed no signs of pain. The family was supported through the interrupted illness process and caregiver education focused on signs, nutrition, and infection prevention.
This clinical concept map summarizes a 10-month-old patient's diagnoses, risks, interventions, and outcomes related to a bowel obstruction and recent surgery. The patient was at risk for infection due to incisions and tubes but remained infection-free. Nutrition was addressed with TPN and monitoring of glucose and electrolytes. Pain was assessed and the patient showed no signs of pain. The family was supported through the interrupted illness process and caregiver education focused on signs, nutrition, and infection prevention.
This clinical concept map summarizes a 10-month-old patient's diagnoses, risks, interventions, and outcomes related to a bowel obstruction and recent surgery. The patient was at risk for infection due to incisions and tubes but remained infection-free. Nutrition was addressed with TPN and monitoring of glucose and electrolytes. Pain was assessed and the patient showed no signs of pain. The family was supported through the interrupted illness process and caregiver education focused on signs, nutrition, and infection prevention.
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CLINICAL CONCEPT MAP
1. Readiness for Enhanced
Nutrition Supporting Data: Successful bowel movement, absence of vomiting after PO intake, expresses willingness to enhance nutrition by reaching for bottle
2. Interrupted Family Process
Labs: TPN panel, metabolic panel,
glucose check Meds:
Pt Initials: AW Age: 10 months Medical Diagnoses:
3. Risk for Infection
Supporting Data: abdominal incisions and presence of tubes, PICC line, TPN Labs: CBC, glucose, any cultures if necessary Meds: Prophylactic antibiotics post op
(Include secondary diagnoses)
Bowel Obstruction, Post Op Day 10
Supporting Data: multiple
hospitalizations within first year of life, history of surgery, history of birth complications, vocalization of stress, unpredictable illness course, discharge needs, economic hardship as evidence by low socioeconomic status, works at Wal-mart- job conflictions with care Labs Meds 5. Risk for Acute Pain related to extensive exploratory surgery
4. Risk for Imbalanced
Nutrition: less than body requirements related to a risk for altered body composition Supporting Data: TPN dextrose 14% 32mL/hr, 768 mL per day continuous, Fat emulsion 20% 250mL bag 2.5mg/kg 4.11mL/hr, prolonged NPO, altered GI tract function, increased metabolic rate Labs: TPN panel Meds:
Supporting Data: bowel
inflammation, intraperitoneal lesions, return to PO nutrition, current FLACC score = 0 Meds: No current meds were listed, previously Tylenol IV and Morphine PRN for first 7 days post op
1. Nursing Interventions: Educate mother on proper nutrition for patient, monitor bowel movements and bowel sounds, monitor gas, assess tolerance of PO intake, determine patterns of hunger 2. Nursing Interventions: Assess caregiver-care recipient relationship, assess familial communication patterns, assess family resources, determine knowledge and ability to provide care, encourage identification of resources whether family or community, teach stress-reducing techniques, provide ample time to discuss concerns, provide illness information, management strategies, and signs and symptoms to look for management (Gulanick & Myers, 2013).
3. Nursing Interventions: Assess patient
temperature, monitor incision for redness, drainage, swelling, and increased pain, wash hands and maintain aseptic technique during dressing changes, monitor TPN dextrose levels and influence on patients glucose, monitor PICC line- watch for redness, swelling, and irritation, only change when needed,
4. Nursing Interventions: maintain potassium
<3.89 mEq/kg/day and calcium <1.94 mEq/kg/day, consult a dietician regarding TPN order, TPN order was 10% dextrose and glucose levels were elevated, dextrose was then increased to 14% and glucose dropped , monitor daily intake and output, assess for the signs and symptoms of electrolyte imbalance, monitor triglycerides, assess hyper/hypoglycemia, 5. Nursing Interventions: Assess signs and symptoms associated with pain, monitor vitals, assess activity, personality, fatigue, and comfort level
1. Expected Outcome: Patient engages in feeding
herself with a bottle and tolerates PO feeding. Evaluation: The patient was able to appropriately reach for the bottle and tolerate PO feeding on the day of discharge as evidence by the absence of emesis. Last bowel movement was recorded 9/29. 2. Expected Outcome: Before discharge, the caregiver will express satisfaction with caregiving role, demonstrate confidence in post discharge care, recognize available resources, and demonstrate flexibility and understanding towards health issues. Evaluation: The patients primary caregiver demonstrated satisfaction after feeding the patient on the day of discharge by smiling and interacting with the patient positively. She expressed excitement to get home, as well as, appropriate understanding of signs and symptoms that would indicate return to the hospital. The caregiver addressed day care as an available resource in the community. She discussed helpful sources within her family as her mother, grandmother, and brother. 3. Expected Outcome: Patient remains free of infection, as evidence by healing of the incision and normal vital signs during hospitalization. Evaluation: Patient was free of infection throughout stay in the hospital as evidence by a temperature of 37.1 and a heart rate of 116.. Mother was educated on cleaning the incision and dressing the incision for prevention of infection at home. The mother was also educated to not bathe the child in a full tub, rather have the child sit in a few inches of water to prevent the water from infecting the incision site. 4. Expected Outcome: The patient will maintain normal serum electrolytes and serum glucose while hospitalized. Mother will be educated on signs and symptoms of hypoglycemia before discharge. Evaluation: The patient showed no signs of hypoglycemia before discharge. The mother was educated and given discharge orders while I was leaving for the day. 5. Expected Outcome: Patient exhibits comfort demonstrated by a return to baseline personality and activity. Evaluation: The patient showed no signs of pain, had normal vital signs as indicated earlier, and a positive overall demeanor as evidence by no crying and return to personality.
Resources Gulanick, Meg; Myers, Judith L. (2013-02-05). Nursing Care Plans: Nursing Diagnosis and Intervention (Kindle Location 1329). Elsevier Health Sciences. Kindle Edition.
