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Tim Efremidis

NUR 4115P
Mrs. Digges
6 West Concept Map

Legend:
Red = Nursing Diagnosis
Blue = Nursing Intervention
Green = Evaluation of nursing diagnosis/interventions
Orange = Assessment data
Purple = Medications
Teal = Rationales
Yellow = Developmental

Intervention:
Elevate HOB
to 30 degrees

Reduce
mechanical
pressure on
airway
clearance

Hx of
GERD

Intervention:
Maintain
proper
medication
regimen
Reduce
exacerbation
of asthma

GERD
can lead
to airway
problems

Break up
secretion and
promote clear
airway

Intervention:
Use CPT vest
for 10 mins, 30
mins after neb
tx.

Zantac
PO-soln
60 mg
BID

S/S improving.
Child was able to
sleep without drop
in pulse ox.

Zyrtec
PO soln
10 mg
daily

Coarse
crackles
auscultated
bilaterally

Need to teach
Nursing Dx #1:
child about
Ineffective airway clearance r/t
when tx is
airway constriction aeb coarse
needed
crackles auscultated bilaterally.
Outcome: Patient will
continue meds, to maintain
open/patent/clear airway.
Need to teach
child about
when tx is
Pulse Ox
needed
drops to
2mg/kg/day
in 2 doses =
2*32=64mg/2
= 32 mg BID

Evaluation: Child was


able to maintain patent
airway; crackles
improved; sp02 remained
>93%

Albuterol
neb 5mg
q3hours

88% when
D.D. sleeps

Orapred
PO soln
32mg
(1mg/kg)

Evaluation: Able to identify


gap in mothers understanding
of rescue inhaler and correct
issue.

Atrovent
neb 0.5
mg
q6hours

Flonase 1
spray
5mcg/spray
q6hours

Med knowledge will


reduce exacerbations
and hospitalizations

Mothers inability to prioritize


and establish support will
further increase exacerbations
related to lack of therapeutic
regimen.

Evaluation: Mother did not go


home, but was able to establish a
support person during hospital stay.

Allergy
to
peanuts

D.D. 6 y.o. Male


Chief complaint: Cough,
difficulty breathing, runny
nose, and fever
Dx: Status Asthmaticus
Code: Full
Admitted on 9/12/14

Improper med
management has
led to 7 ED visits
in 2 years. Should
be able to manage
with proper med
administration.

Weight:
32 kg

Need to teach
child about
when tx is
needed

Nursing Dx #2:
Ineffective therapeutic regimen
r/t excessive demands made on
mother aeb increased illness
symptoms.
Outcome: Mother will be able
to verbalize therapeutic
regiment of child and establish
one support person.

Eczema
present on
skin.

Intervention:
Assist mother in
setting realistic
goals during
hospitalization

Partially
completed
goal; Mother
verbalizes
need to care
for other
children

Reduce stress
and form a
plan of action

Developmental: Child verbalizes he


uses mask to breath in medicine
every 3 hours. Also verbalizes, I
take my medicine in the morning.
(Piaget Pre operational stage)

Aid in
formulating
proper
teaching

Help to
understand
why/what med is
important

Help child learn


how to manage
own disease

Intervention:
Assess prior
efforts to follow
regimen

Intervention:
Keep child busy
so mother can go
home for two
hours

Allow mother to care


for 2 other children at
home; Mother is
single

Nursing Dx #3:
Interupted family process r/t
changes in family roles aeb
mothers report of hardship with
caring for two other children.
Outcome: Provide child and
mother support so mother can go
care for two other children for two
hours.
Lack of support
(single mother)
does not allow for
proper care of all
3 children. Oldest
son also has
asthma but not as
severe.

Intervention:
Assess knowledge
of how regimen
helps prevent
symptoms
Intervention:
Assess childs
ability to explain
use of regimen

Promote
understanding of
disease progression;
prevent
hospitalizations

Intervention:
Provide education
on disease to
prevent further
hospitalizations (7
in past 2 yrs)