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. Nursing Care of the Child Concept Map
| Category
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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.
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| LOC |
Increased acuity |
| Patient is talking but slurring his words. Pupils are dilated. |
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| Pain |
Increased acuity |
| Patient states his headache is getting “worse”. |
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| Psych |
Normal acuity |
Status assessment reports no indication of increased Psychiatric acuity
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| Safety |
Increased acuity |
Patient has IV of LR infusing at 125 ml/hour to left forearm making him a fall risk.
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Diagnosis
| Deficient Knowledge |
Status assessment reports signs of neurological deficit (slurring of words, pupils dilated, headache getting worse).
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| Risk for injury |
Status assessment reports signs of neurological deficit and has an IV line.
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| Acute pain |
| Status assessment reports headache is getting “worse”. |
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| Risk for aspiration |
| Patient with neurological deficit should not have anything to eat or drink. |
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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)
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320mg |
TID |
Oral |
| dexamethasone (Dexamethasone)
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30mg |
Once; 50 mls NS bag over 30min
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IV |
| phenobarbital-oral sol (phenobabital )
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2mg/kg |
bid |
po |
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| 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 |
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Chief Complaint
Admitting Diagnosis & Admission Date
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| 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) |
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| Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage with real examples (based on objective assessment) |
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| Concept Map
Student Name:
Instructor:
Date of Care:
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| Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
| Lab Tests |
Normal Ranges |
Admission Lab Values
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Current Lab Values |
Explain Abnormal Labs R/T Your Pt |
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INCLUDE: Appro. Diagnostic Tests/ Procedures- DATEs and RESULTS |
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| 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.
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| 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 |
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| ASSESSMENT/
REVIEW OF SYTEMS
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| Cardiovascular (6)
FOCUSED
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| Musculoskeletal
(8)
PALPATION
ASCULTATION
-OR- |
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| GI
Hydration/Nutrition (9)
TO
TOE |
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| Endocrine (13)
ASSESSEMENT
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| Integumentary (12)
ASCULTATION
PALPATION |
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| Priority Nursing Diagnosis #2
APPROPRIATE NSG DX
WRITTEN CORRECTLY
i.e. Nsg. DX. R/T _________ AEB à assessment findings/ diagnostics___________
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| Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED |
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| Evaluation #1
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
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| 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) |
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| Outcome/Goal #1
S-PECIFIC
M-EASURABLE
A-TTAINABLE
R-EALISTIC
T-IMED |
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| Evaluation #2
GOAL MET
GOAL PARTIALLY MET (EXPLANATION OF PARTIAL)
GOAL NOT MET (EXPLANATION OF WHY-NOT MET)
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| 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
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| 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)
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