Nursing Concep Map

INSTRUCTIONS

Fill out the attached chart (empty one) with the patient information post below. Whatever is not listed in the chart must be made up. Absolutely everything in the nursing concept map needs to be filled out even if the information isn’t provided. For the nursing diagnosis it must be in the format of “at risk for” ……..“related to……, as evidence by” and another one that is “at risk for”…. “Related to”… You will see where you have to write the nursing diagnosis on page number 2 of the nursing concept map. EVERYTHING MUST BE REFERENCED. ( In cite citation, and apa references at the end) Again, whatever you don’t find in the pictures below must be MADE UP. This is for my pediatrics nursing class.

· I’M PROVIDING A CONCEP MAP EXAMPLE FROM PREVIOUS CLASS FOR YOU TO HAVE A SPECIFIT IDEA OF HOW TO FILL THIS OUT! (ATTACHED AS A DIFFERENT DOCUMENT)

Patient Information Below:

Jonathan Gibbons Room 301

Jonathan Gibbons, 13-year-old male diagnosed with asthma since he was 3 years old. He uses a rescue albuterol inhaler (PRN) on an "as needed" basis. Jonathan presents to the clinic with what his mother calls a “bad cold and cough” that has been present for 3 days. Vital signs and assessment: B/P 110/65 T100.8* HR 110 RR 26, PaO2 92%. Bilateral wheezing can be heard throughout all lung fields. Jonathan is seen in a tenting position and using accessory muscles to breathe. He has been using his rescue albuterol inhaler q 2 hours for the last 6 hours with minimal relief. Orders: Admit to the pediatric unit at Children’s hospital, IV methylprednisolone 40mg q day, Ampicillin 250 mg IV q 6 hours, Tylenol 500 mg PO q 6 hours prn Temp/Pain, Xopenex 0.63 mg q 6 hours per nebulizer and PRN.

Educational needs increased acuity: status assessment reports patient waited longer than expected. Needs education regarding treatment elapse time.

Health increased acuity: status assessment reports patient with a bad cough and abnormal vital signs

LOC normal acuity: status assessment reports no indication of increased LOC acuity

Pain increased acuity: status assessment reports patient is in tenting position and using accessory muscles to breathe

Psych normal acuity: status assessment reports no indication of increased psychiatric acuity

Safetyincreased acuity: status assessment reports patient has IV therefore making him a fall risk

Physiological

-impaired gas exchange, risk for: status assessment reports patient is in tenting position and using accessory muscles to breathe with abnormal lab signs

-pain, at risk acute: status assessment reports tenting position and using accessory muscles to breathe resulting in pain

-respiratory distress: status assessment reports patient bilateral wheezing throughout all lung fields and seen in a tenting position using accessory muscles to breathe

Safety

-knowledge deficit: status assessment reports patient waited 3 day to seek medical attention. Needs education regarding treatment elapse time.

Scenario 1: Johnathan staes he is having increased difficulty breathing over the last 20 minutes

Place in the correct order

1. Assess bilateral lung sounds and O2 saturation, bilateral wheezing noted, o2 sat 88%

2. Reassure jonathan that he will be taken care of

3. Notify RT for Xopenex PRN

4. Reassess bilateral lung sounds and 02 saturation

5. Document findings

Scenario 2: Jonathan complains of just not feeling well and is jittery from the Xoepenex

1. Assess vital signs

2. Administer acetaminophen 500 mg PO

3. Explain to jonahtan that the jitteriness is an expected side effect of the Xopenex and will and will get better with time

4. Reassess temperature in 30 mins

5. Document findings

Scenario 3: jonathans grandparents come to visit. The nurses note a strong cigarette smell on their clothes

1. Ask the grandparents if they smoke and if they do if they smoke in the house or around Jonathan

2. Educate the grandparents on the dangers of second hand smoke that can exacerbate jonathans asthma

3. Educate Jonathan and his parents of the dangers of being around second hands smoke

4. Talk with Jonathan about other triggers that he is aware of for his asthma

5. Educate Jonathan about triggers that he might not be aware of

Scenario 4: Jonathan is playing baseball with his friends. While on the field, he notices that he is having difficulty breathing. He comes to the school nurse for help

1. Assess breath sounds, notes inspiratory wheezing

2. Administer MDI albuterol inhaler 2 puffs (kept in school nurse office)

3. Reassess lung sounds. Inspiratory and expiratory wheezes now present. Jonathan is showing increased signs of anxiety

4. Administer 2nd dose of MDI. Have Jonathan to loosen clothing and assume a tent position. Wheezing worsening

5. No improvement in vital signs. Notify MD and 911 for transport to hospital

Scenario 5: Jonathan is admitted to the Pediatric ER. Lung sounds reveal inspiratory and expiratory wheezing, RR 34 and shallow, lips and nails blue, HR 150. Pediatric Asthma score is 8.

1. Apply continuous cardiopulmonary and pulse ox monitors

2. Administer corticosteroids

3. Administer albuterol neb

4. Reassess pediatric asthma score

5. Admit to PICU for further treatment

Medication Stock Room

Medication Stock Room

Acetaminophenanalgesic : 1 tab at 0600, 0900, hold at 1200, give again at 1800, 2200

Ampicillin immunological system: 133 at 0600, 1200, 1800, 2200

Methylprednisolone IV 100 at 0900