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Concept Mapping
4832 Nursing Care of Children and Families
Hannah Shafer

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Step 1. Write the key problems the patient has based on the data collected. The key
problems are also known as the concepts. Start by centering the reason for seeking health
care (often a medical diagnosis). Next, list the major problems you have identified based
on the assessment data collected on the patient.

Key Problem Key Problem Key Problem

Risk for ineffective airway Risk for abnormal or Risk for inadequate
clearance change in vital signs nutrition: less than body
requirements

Key Problem
Key Problem Reason For Needing Health Care Risk for electrolyte
Risk for acute pain Diagnosis of RSV imbalance
Brue
Laryngospasm
Bronchiolitis

Key Problem Key Problem Key Problem

Risk for further Increase movement of Knowledge deficit related
complications related to extremities to promote to care of patient
positive RSV blood flow to body tissues

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Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab Data don’t
know where
tests, medical history, emotional state and pain. Also, identify key assessments that are
to put in
related to the reason for health care (chief medical diagnosis/surgical procedure) and put boxes:
these in the central box. If you do not know what box to put data in, then put it off to the
side of the map.
#3 Key Problem/ND #7 Key Problems/ND #5 Key Problem/ND
Risk for nutritional Knowledge deficit Risk for worsening of
imbalance Supporting Data Condition Supporting Data
Supporting Data Normal vital signs Inadequate oxygen
Hx of reflux of formula treatments perfusion
High calorie formula Need for upright position Cool extremities
related to low weight after feeds Mottled skin
Hx of inability to complete Warning signs that Change in temperature
all formula during feedings condition decreased during shift
Need for isolation

#1
Key Problem/ND:
Impaired gas exchange/ineffective #2
airway clearance/ineffective
breathing patterns/risk for Reason For Needing Health Care Key Problem/ND
infection RSV, Brue, Laryngospasm, Bronchiolitis Risk for abnormal or
Supporting Data Key Assessments: adventitious lung sounds, change in vital signs
O2 100 irregular temperature, previous reflux Supporting Data
Drainage from mouth and nose Lung sounds: Expiratory wheeze Temp 38.1
Hx of reflux Pulse ox: 100 Mottled skin
Mottled skin Temp: 38.1 then 36.0 upon reassessment Lack of movements
Demonstrated signs of discomfort Resp. rate and effort: 48 and labored at times
Adventitious lung sounds Skin color: normal for ethnicity, mottled
HOB elevated 30 minutes when cold
following a meal 5 week old patient
Heart rate 167 Cap refill: less than 3 seconds #8
Respiratory rate 48 O2/mist tent: No oxygen therapy given on
Copious clear nasal secretions day of care Key Problem/ND
Heart rate: 167 Risk for Electrolyte Imbalance
Risk for overall discomfort Supporting Data:
Supporting Data #6
Key Problem/ND Hx of reflux
Fussy at times Inability to finish dose of
Inadequate rest periods
Appeared restless formula during feeds
#4 Supporting Data:
cluster care for rest periods
Patient was fussy at times
administer prn pain medication
In need of frequent rest periods
to reserve energy
Poor oxygen perfusion to tissue

Problem # 1: Risk for effective airway clearance

General Goal: patient will maintain a patent airway
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Predicted Behavioral Outcome Objective: The patient will demonstrate effective airway
clearance with no signs of cyanosis, dyspnea and keep a patent airway during my shift.

Nursing Interventions Patient Responses

1. Assess rate, rhythm, and effort of respirations 1. WDL

2. Assess sputum color, velocity, and quantity. 2. No sputum was present, cough was dry
3. Provide adequate fluids 3. Patient consumed 3 ounces of formula
4. Elevate HOB and change position frequently 4. Patient was content in crib
5. Deep breathing and coughing, suction PRN 5. No suction needed
6. Monitor pulse ox 6. Pulse ox was above 90
7. Use of appropriate medication 7. Interventions were successful

Evaluation of outcomes objectives: Outcomes were MET

Problem # 2:Risk for abnormal vital signs

General Goal: Maintain Vital Signs within defined limits

Predicted Behavioral Outcome Objective (s): The patient will demonstrate vital signs within
defined limits on day of care

on the day of care.

Nursing Interventions Patient Responses

1. Monitor VS as ordered 1. VS taken upon assessment

2. Monitor for signs of distress 2. Patient remained calm on day of care
3. Monitor for signs of fever 3. Patient has temporary increase in temperature
4. Report any abnormal values to nurse 4. Increased temperature was reviewed by nurse and physician

Evaluation of outcomes objectives: Outcomes were MET

Problem #3 risk for nutrition imbalance

General Goal: to maintain adequate nutrition for age based on growth chart

Predicted Behavioral Outcome Objective: The patient will demonstrate an increase in appetite
during my shift.

Nursing Interventions Patient Responses

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1. Supply small frequent feedings 1. Patient consumed formula

2. Monitored for any reflux 2. Was successful
3. Pain medication given before meals 3. Patient appeared to not be in pain
4. Monitor weight, including daily weights 4. Patients weights were recorded

Evaluation of outcomes objectives: Outcomes were MET

Problem #4: Risk for overall discomfort related to ineffective breathing pattern
General Goal: Decrease pain

Predicted Behavioral Outcome Objective: The patient will maintain their acceptable level of pain
during my shift.

Nursing Interventions Patient Responses

1.Provide comfort measures 1. This was successful

2.Administer analgesics as prescribed 2. This was successful, and also helped inc appetite
3. Use distractions such as being held 3. Patient enjoyed grandmother interaction
4. Peak- a- boo 4. Patient was interested by this

Evaluation of outcomes objectives: Outcomes were MET

Problem # 5 Worsening of condition related to poor oxygen perfusion

General Goal: Prevent further complications of RSV by preventing reflux

Predicted Behavioral Outcome Objective (s): The patient will not exhibit signs of a worsening
condition on the day of care

Nursing Interventions Patient Responses

1. Encourage full dose of formula 1. Patient finished order dose

2. Administer ordered medication 2. Patient finished course of steroid treatment
3. Sit patient up for 30 minutes after 3. Patient maintained upright to reduce risk of aspiration
meals
4. Encourage family to frequently 4. Family was compliant with precautions and handwashing
wash hands and follow contact and
Droplet precautions

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Evaluation of outcomes objectives: Outcomes were MET

Problem #6: Inadequate rest periods

General Goal: Improve Activity

Predicted Behavioral Outcome Objective: The patient will ambulate 3 times around room, once
after each meal during my shift.

Nursing Interventions Patient Responses

1. Promoting rest, dark doom, limit stimuli 1. This was successful to rest before interventions
2. Determine the response to activity 2. The patient tolerated well
3. Pace interventions 3. Group the nursing interventions to promote rest
4. Asist with self-care activity’s 4. Was successful

Evaluation of outcomes objectives: Outcomes were MET

Problem # 7: Knowledge deficit related to patient’s disease process

General Goal: Increase the family’s knowledge

Predicted Behavioral Outcome Objective: The patient’s family with discuss the new information
with me before discharge and ask any questions.

Nursing Interventions Patient Responses

1. Determine the family’s knowledge

Of RSV 1.the family had deficient knowledge
2. Review of respiratory function 2. Responded well
3. Allow time to process and ask Q’s 3. The patient’s family asked about the disease process
4. Assess for any home care needs 4. Family understand importance of handwashing

Evaluation of outcomes objectives: Outcomes were MET

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Problem # 8: Risk for electrolyte imbalance related to reflux

General Goal: Maintain adequate hydration, and electrolytes.

Predicted Behavioral Outcome Objective: The patient will increase fluid intake to at least 8 oz at
each meal.

Nursing Interventions Patient Responses

1. Provide formula as prescribed 1. Patient consumed all ordered doses

2.Asess vital signs 2. Vital signs were WDL
3. Monitor I and O closely 3. Patient/ family let me know when the child had voided
4. Assess electrolytes and lab values 4. Before discharge was WDL

Evaluation of outcomes objectives: Outcomes were MET

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