Nursing Map

NIGHTINGALE COLLEGE DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET

NURSING PROCESS TEMPLATE:

Assessment (Recognizing Cues)

Which patient information is relevant? What patient data is most

important? Which patient information is of immediate concern?

Consider signs and symptoms, lab work, patient statements, H & P,

and others. Consider subjective and objective data.

Vital signs: Fevers can indicate infection and/or inflammation. Low oxygen saturation levels (< 90%) can indicate inflammation in the airways. Heart rate and respirations: Tachycardia and tachypnea are both signs of an inflammatory response in the airways, or asthma. Lung sounds: Wheezing can indicate a partially blocked airway or swollen bronchiole tubes from inflammation (Cleveland Clinic, 2020b). This client had inspiratory and expiratory wheezes, telling us that he had inflammation in his bronchiole tubes. Medical History: 5-year-old boy with a history of asthma and currently has a fever. Caregiver reports that inhaler has not been helping.

Analysis (Analyzing Cues)

Which patient conditions are consistent with the cues? Do the cues support a particular patient condition? What cues are a cause for concern? What other information would help to establish the significance of a cue?

One condition that is consistent with the cues is severe acute asthma exacerbation. Another is that the client may have a respiratory tract infection. Because of these conditions, the bronchioles have become inflamed, and the client has classic symptoms of an asthma exacerbation: tachypnea, tachycardia, diaphoresis, wheezing, shortness of breath, and chest tightness (Jafarnejad & Khoshnezhad, 2020).

Analysis (Prioritizing Hypotheses)

What explanations are most likely? What is the most serious explanation? What is the priority order for safe and effective care?

The client is most likely suffering from an asthma attack, which includes inflammation and narrowing of airways. This could be related to a respiratory infection affecting the airways. The most serious explanation at this time would be a severe asthma attack affecting the client’s ability to breathe. The priority for safe and effective care for this client would include maintaining patent airways and an adequate oxygen saturation level.

Planning (Generate Solutions)

What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning- specific, measurable, attainable, realistic/relevant, time-restricted- Goal setting)

Achieve and maintain control of symptoms: medications, fluids, oxygen.

Prevent respiratory decline: monitor client for any indication of decline and treat as necessary.

Avoid dehydration, respiratory irritants, missing medications, excessive physical activity during acute exacerbation.

Implementation (Take actions)

How should the intervention or combination of interventions be performed, requested, communicated, taught, etc.? What are the priority interventions? (Mark with asterisk)

Positioning the client in a high-fowlers or semi-fowlers can help with dyspnea while undergoing nebulizer therapy (Chanif & Prastika, 2019). Offer the client water to help thin secretions and hydrate. Some clients may experience a dry mouth from corticosteroids (Hira et al., 2015). Water can also be

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soothing since the client has a slight fever and is feeling warm. Client (and caregiver) education. This client is only 5 years old so it can be helpful to show him how to properly use his inhaler (with a chamber) by demonstrating on a stuffed animal or inanimate object (LaRue & Kelly, 2015). The caregiver should be educated on the medication regimen, as well as how to use the inhalers and nebulizer treatments. We should teach her the importance of the treatments and when to call the provider. It is important to inform her of common irritants such as being exposed to smoke, dust, and pets (National Asthma Council, 2022). Therapeutic communication: Since this is a pediatric client, earning his trust can be tough but very important so that he will feel safe with us and be more likely to comply with the treatment. We must ask permission before performing examinations and explain the process as well as what he can expect. Offer to turn on a movie or music for him. We want the client to stay calm, comfortable, and happy. The distraction of the television may help him rest and feel more comfortable in such a stressful situation and setting, being away from home (Children’s Hospital of Pittsburgh, 2022).

Evaluation (Evaluating Outcomes)

What signs point to improving/declining/unchanged status? What interventions were effective? Are there other interventions that could be more effective? Did the patient’s care outlook or status improve?

Before the assessment in the ED the client was not using the spacer and was inhaling too fast (the client should take a slow, deep breath). The nurse identified lack of coordination between activating the inhaler and initiating the deep breath, angling the inhaler to spray the tongue or side of the mouth, and the client failing to hold his breath for 10 seconds after inhalation. If this kind of management continues, client will not get the necessary medication he needs when another attack occurs. Client’s cough has subsided and has been able to relax without breathing difficulty. Oxygen saturation improved to 96%. Client’s heart rate and respiratory rate have dropped to WNL. Intermittent expiratory wheezes still present but diminishing.

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Patient Information (SBAR)

Main Concept

(Should be focus of below map)

Disease Process/Pathophysiology/Risk Factors

Recognizing Cues, (S&S)

Analyzing Cues/Concerns

Prioritizing Hypotheses

Asthma is an airflow obstruction due to bronchial

hyperresponsiveness and underlying inflammation. The

bronchoconstriction quickly occurs to narrow the

airways due to stimuli such as irritants, allergens, or

infection. During an exacerbation, the epithelial cells

that line the airway initiate an inflammatory response,

causing the airways to become inflamed and begin to

swell and narrow. The muscles around the airway

contract and produce more mucus which leads to

further narrowing of the bronchial tubes.

• Step 1 – Mild intermittent asthma. Symptoms fewer than two times a week.

• Step 2 – Mild persistent asthma. Symptoms more than two times a week, but no more than once a day.

• Step 3 – Moderate persistent asthma. Symptoms every day.

• Step 4 – Severe persistent asthma. Constant symptoms.

Risk Factors: Allergies, family history, secondhand smoke, environmental exposures, more prevalent in children

S: 5-year-old boy with an apparent acute

severe exacerbation of asthma.

B: The client was alert and speaking in short

sentences due to shortness of breath.

Inspiratory and expiratory wheezes audible

without the use of a stethoscope. Fever of

100.4 F, HR of 130 bpm, RR 40 bpm, O2 sat

of 90%. Patient has NKDA and no significant

past medical history other than diagnosis of

asthma.

A: I think the patient is experiencing asthma

exacerbation possibly due to respiratory

illness.

R: I recommend starting nebulizer

treatments and would like you to come place

orders as soon as possible, please.

INFLAMMATION

Prioritize client conditions and care:

1. Wheezing/dyspnea

2. Hypoxia

3. Fever

• Respiratory rate – 40 bpm

• Low oxygen saturation - 90%

• Fever - 100.4 F

• Chest tightness

• Inspiratory and expiratory wheezes

• Rapid heart rate – 130 bpm

Supporting connections between the cues

(S&S) and the client condition:

• Wheezing indicates bronchiole

inflammation causing airway

constriction.

• Dyspnea (shortness of breath)

causes tachypnea and tachycardia.

• Hypoxia (low oxygen saturation) is

related to the impaired gas

exchange due to the airway

constriction.

• Fever is related to suspected

respiratory infection.

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Generate Solutions/Outcomes/Interventions

SMART Planning Taking Action – (How To)

Evaluating Outcomes

1. Apply nasal cannula and titrate oxygen to

maintain oxygen saturation >95%.

2. Administer medications/breathing treatments

as directed to decrease inflammation and

wheezing. Listen to lungs every 30 minutes x2

hours to assess for wheezing.

3. Position the client in a high-fowlers or semi-

fowlers position to maintain airway clearance.

4. Administer antipyretic medication as need to

decrease fever and provide comfort.

5. Educate the client and caregiver regarding plan

of care, medications, and inhaler use. Verbalize

and demonstrate correct spacer use and

educate on importance of proper use.

1. The client’s O2 saturation was 98% on room air without evidence of dyspnea or chest tightness following

oxygen therapy.

2. Client’s respiratory rate decreased to 24 bpm and heart rate decreased to 100 bpm. Client verbalized ease of

breathing. Mild intermittent expiratory wheezes audible only with stethoscope.

3. Client able to sit upright to expectorate mucus and maintain airway clearance. Lungs clear with intermittent

expiratory wheezes.

4. Client’s temperature decreased from 100.4 F to 98.9 F by end of shift.

5. Caregiver and client demonstrated the appropriate use of inhaler with spacer, ensuring client inhales the

amount of medication needed, optimizing the effectiveness of the medication.

6.

4.

5.

1. Within 30 minutes of breathing treatment

and application of supplemental oxygen via

nasal cannula, client will obtain and maintain

oxygen saturation levels >95%.

2. Within 30 minutes of breathing treatment,

respiratory rate will be within 20-30 bpm and

heart rate will be within 75-115 bpm.

3. Client will have improved airway clearance

related to repositioning as evidenced by clear

lung sounds in all four lung fields anteriorly and

posteriorly by the end of the shift.

4. By end of the shift, client’s temperature will

be decreased from 100.4 F down to <99 F

following antipyretic medication administration.

5. By end of shift, client will correctly

demonstrate the use of inhaler spacer three

times, as a result of proper client and caregiver

education.

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References

Children’s Hospital of Pittsburgh. (2022). Distraction techniques | Children’s Hospital Pittsburgh.

https://www.chp.edu/our-services/radiology/our-approach/distractiontechniques

Cleveland Clinic. (2020b). Wheezing: Definition, causes & treatment.

https://my.clevelandclinic.org/health/symptoms/15203-wheezing

Giddens, J. F. (2017). Concepts for nursing practice (2nd ed.). Elsevier.

Jafarnejad, S., & Khoshnezhad Ebrahimi, H. (2020). Clinical guidelines on pediatric asthma exacerbation in emergency

department, a narrative review. European journal of translational myology, 30(1), 8682.

https://doi.org/10.4081/ejtm.2019.8682

National Asthma Council. (2022). The National Asthma Council Australia. https://www.nationalasthma.org.au/living-

with-asthma/resources/patientscarers/factsheets/pets-and-allergies