Nursing Care of the Child Concept Map

Nursing Care of the Child Concept Map

Nursing Care of the Child Concept Map

 

Patient Information

Sam Knight, A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular.

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Category

 

Acuity Explanation
Educational Needs Increased acuity Possible subdural hematoma and concussion will require educational directions
Health Increased acuity Patient is talking but slurring his words. Pupils are dilated … states his headache is getting “worse” and is complaining of nausea.

 

LOC Increased acuity
Patient is talking but slurring his words. Pupils are dilated.

 

 

Pain Increased acuity
Patient states his headache is getting “worse”.

 

 

Psych Normal acuity Status assessment reports no indication of increased Psychiatric acuity

 

Safety Increased acuity Patient has IV of LR infusing at 125 ml/hour to left forearm making him a fall risk.

 

 

 

Diagnosis

Deficient Knowledge Status assessment reports signs of neurological deficit (slurring of words, pupils dilated, headache getting worse).

 

Risk for injury Status assessment reports signs of neurological deficit and has an IV line.

 

Acute pain
Status assessment reports headache is getting “worse”.

 

 

Risk for aspiration
Patient with neurological deficit should not have anything to eat or drink.

 

 

 

 

Scenarios

1-You have an order for Mannitol IV push to be given and you are to assess for increased ICP. Upon entering the room, you notice the overhead lights are bright and bed alarm settings are on high.

2-You are directed to implement measures to reduce increased ICP.

3-Moments after entering the room, Sam begins experiencing a grand mal (tonic-clonic) seizure.

4-Sam has a sluggish return to cognitive abilities. He is in ICU two days post seizure episodes.

5-Educate Sam on concussion symptoms and prevention of further injury.

 

Patient Info

DOB: 8/19/2003 (17yo)

MRN: 82911040

Weight: 180 lbs

Diagnosis: Head Injury

Allergies: None

Provider: Dr Childs

 

Meds:

Drugs Amount Frequency Route
Acetaminophen, Childrens (Tylenol)

 

320mg TID Oral
dexamethasone (Dexamethasone)

 

30mg Once; 50 mls NS bag over 30min

 

IV
phenobarbital-oral sol (phenobabital )

 

2mg/kg bid po
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

WHAT BROUGHT THE PT TO THE HOSPITAL?   WHAT EVENTS LEAD UP TO THIS?  WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL? (USE SEPARATE SHEET WHEN NEEDED)

 

 

 

 

 

 

Medical History:

PAST DIAGNOSED MEDICAL PROBLEMS

 

 

 

 

 

Surgical History:

PAST DIAGNOSED SURGICAL PROBLEMS

 

 

 

 

Social History:

SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE

 

Chief Complaint

 

 

 

 

Admitting Diagnosis & Admission Date

 

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)

❋Economic Stability

❋ Education -school

❋Social and Community Context

❋ Health and Health Care

❋ Neighborhood and Built Environment

Parents-Who takes care of the child at home?

Siblings

Extended Family

 

 

(based on objective assessment)

Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage with real examples (based on objective assessment)
Concept Map

Student Name:

Instructor:

Date of Care:

 

 

 

Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)

 

 

Lab Tests Normal Ranges Admission       Lab Values

 

Current Lab Values Explain Abnormal Labs R/T Your Pt
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCLUDE:  Appro. Diagnostic Tests/ Procedures- DATEs and RESULTS

 

Patient Education (In Pt.) for Transfer/ Discharge Planning

 

ASSESS LEARNING STYLE:

LEARNING PREFERENCE: WRITTEN, VIDEO, etc.

 

LEARNING BARRIER(S): Patient’s age, Parents Present, LANGUAGE, EDUCATION LEVEL

ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.

 

 

 

 

 

 Medications & Allergies (2)

 

Medication Name Dose –

Show math with mg/kg for your patient’s weight

Route Freq. Indications (PRN meds must include MD ordered Indication) Mechanism of Action Side Effects/

Adverse Reactions

Nursing

 Considerations

RN Considerations
                 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSMENT/

REVIEW OF SYTEMS

 

Respiratory (7)

 

 

 

 

Neurological (5)

 

 

 

HEAD

 

Cardiovascular (6)

 

 

 

FOCUSED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  Musculoskeletal

(8)

 

 

 

PALPATION

ASCULTATION

 

 

 

-OR-

 

Rest/ Exercise (11)

 

 

 

 

 

 

GI

Hydration/Nutrition (9)

 

 

TO

 

 

TOE

GU (10)

 

 

 

ASSESSMENT

 

Endocrine (13)

 

 

ASSESSEMENT

 

Misc.

 

Psychosocial (14)

 

 

 

Integumentary (12)

 

 

 

ASCULTATION

PALPATION

 

 

 

Priority Nursing Diagnosis #2

APPROPRIATE NSG DX

WRITTEN CORRECTLY

i.e.  Nsg. DX.   R/T _________ AEB  à assessment findings/ diagnostics___________

 

Outcome/Goal #1

S-PECIFIC

M-EASURABLE

A-TTAINABLE

R-EALISTIC

T-IMED

 Evaluation #1

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET)

 

Interventions # 2

 

ASSESS:  system, site, pt problem

MONITOR:  labs, dx, loc

NON PHARM:  reposition, elevate/lower hob/extrem. cool measures (heat/ice),

ambulate, imagery/distraction, incentive spirometer, tcdb.

ADMIN MEDS: r/t to problem

PT EDU:  meds, treatments, tests, procedures, room/unit/phone/visitors

COLLABORATE: w/MDT & update MD/PA/NP

 

(Enough to accomplish the Goal)

Outcome/Goal #1

S-PECIFIC

M-EASURABLE

A-TTAINABLE

R-EALISTIC

T-IMED

Evaluation #2

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET)

 

At Risk Interventions

(TO PREVENT BECOMING ACTUAL PROBLEM)

ASSESS:  system, site, pt problem

MONITOR:  labs, dx, loc

NON PHARM:  reposition, elevate/lower hob/extrem. cool measures (heat/ice),

ambulate, imagery/distraction, incentive spirometer, tcdb.

ADMIN MEDS: r/t to problem

PT EDU:  meds, treatments, tests, procedures, room/unit/phone/visitors

COLLABORATE: w/MDT & update MD/PA/NP

 

At Risk Evaluation Plan

 

GOAL MET

GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)

GOAL NOT MET (EXPLANATION OF WHY-NOT MET and possible revision of plan)

 

At Risk Outcomes/

Goal

S-STATES, PRESENTS, WILL BE ABLE…

M-AMOUNT, NO. OF TIMES…

A-TTAINABLE

R-EALISTIC

T-w/IN THE HOUR(S), BY END OF SHIFT, BY DISCHARGE DAY

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