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Pediatric Concept Map
2
Pediatric Concept Map
Megan Weber
11/07/2022
Physical Exam Measurements:
Weight loss of 0.8kg since admission, diminished lung sounds on left side, chest tube with thickened drainage, coughing, and oxygen saturation between 80% and 99% on room air.
Physical Exam Measurements
History of present illness:
8 days prior to admission, the patient developed a cough and congestion. The patient also had persistent fever and increased work of breathing. The patient was diagnosed with RSV and was noted to have a left sided pneumonia with effusion. The patient was admitted with respiratory distress and hypoxia. When admitted the patient was to tachypneic (80-100) and was put on 6Lof high flow with 60% FIO2. The patient was sedated for a left lateral chest tube placement. After this, breathing improved and the patient was noted to have a strong cough. The patient had poor oral intake. The patient was weaned to 3L and 30%, then to room air, with saturations above 90%. Due to continued poor oral intake a nasogastric tube was placed. The patient currently remains on room air, is tachycardic and tachypneic, and has very minimal oral intake.
History of Present Illness
Nutritional History:
The patient has had poor oral feeding. The patient also lost 0.8kg since admission. A nasogastric tube was placed. The patient is currently receiving enteral nutrition, in the form of total pediatric, at 130mL/hr every 4 hours. The patient has started to minimally eat some food orally.
Nutritonal History
Past medical history:
Past Medical History
The patient was born premature at 25 weeks. The patient has had no previous health problems and has no daily medications. The patient has had no prior hospitalizations or surgeries. The patient is up to date on vaccinations.
Supporting labs/procedures/diagnostic tests:
Supporting Labs/Diagnostics/Procedures
Labs that were done include a CBC, which showed elevated WBC, and blood chemistry, which showed a low albumin and low CRP. The pleural fluid was also tested. Additional procedures and diagnostic tests that were performed include a CT scan, which showed consolidation and necrotizing pneumonia.
Priority Nursing Diagnosis:
Priority Nursing Diagnosis
Ineffective breathing pattern related to respiratory distress and fatigue as manifested by abnormal breathing pattern, tachypnea, low SpO2, and use of accessory muscles to breathe.
Goal:
The patient will demonstrate a breathing pattern that supports blood gas results within normal limits during the shift.
Goal
2 outcome criteria:
-The patient will demonstrate unlabored breathing including no use of accessory muscles to breathe.
-The patient’s vitals will be within normal parameters including SpO2 above 95%, and between 22 and 40 breaths per minute.
2 Outcome Criteria:
Interventions:
-Monitor the patient’s respiratory rate, depth, and work of breathing to assess for any new or worsening signs of respiratory distress or ineffective breathing pattern.
-Administer medications and oxygen as needed and as ordered. Ensure that if using a nasal cannula or mask that it is properly secured to the child’s face to prevent them from pulling it off, this also includes potentially restricting range of motion such as with no-no’s.
Interventions:
-Assist the patient into a comfortable position that promotes an effective breathing pattern. This could include involving family members to sit with the child and help comfort, calm, and support the child.
-Educate the family on the signs and symptoms of ineffective breathing pattern and respiratory distress including tachypnea, and the use of accessory muscles to breathe. Educate the family to report these new or worsening symptoms to the provider.
Evaluation of goal:
This goal was partially met. During the shift the patient did demonstrate an unlabored breathing pattern and did not use any accessory muscles to breathe. However, the patient’s respiratory rate was tachypneic at times, and their SpO2 did drop to below 95% on room air at times throughout the shift.
Evaluation of goal:
References:
Ackley, B., Ladwig, G., & Makic, M.
(2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). St. Louis, MO: Elsevier.
Hockenberry, M., Wilson, D., &
Rodgers, C. C. (2019). Wong’s nursing care of infants and children (11th ed.). St. Louis, MO: Elsevier Health Sciences.