1

Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab tests, Data don’t
medical history, emotional state and pain. Also, identify key assessments that are related know where to
to the reason for health care (chief medical diagnosis/surgical procedure) and put these in put in boxes:
the central box. If you do not know what box to put data in, then put it off to the side of
the map.

#1 Key Problem/ND: Risk for #5 Key Problems/ND: Anxiety #6 Key Problem/ND: Delayed
electrolyte imbalances. - grinds teeth when anxious Growth and Development (r/t
- High fever >101 degrees F - Fidgeting Down Syndrome)
- High HR above 200 bpm in the - Given Denedryl to help fall - wears diapers at 8 years old
ED asleep - Only eats baby food
- IV therapy : 0.9% NaCl with KCl - Poor eye contact - Speaks in few words/
- Skin turgor not elastic / slow - Still posture during patient care understands a few words
- 18.8 CO2 at admission - Needs extra IV site protection
- BUN ranged from 8-21 over last or patient will pull out IV
few weeks - Needs mom’s assistance for
all daily cares

# Key Problem/ND:
# Key Problem/ND

Reason For Needing Health Care

(Medical Dx/ Surgery)

Dehydration related to gastroenteritis

Key assessments: Vital Signs, I&O, SPO2,
skin turgor and color, weight, capillary
refill, bowels sounds, lung sounds, heart
sounds

#3 Key Problem/ND: Diarrhea #2 Key Problem/ND: Nausea / #4 Key Problem/ND: Parents

- hyperactive bowel sounds on Vomiting Deficient in knowledge r/t
admission day - given Zofran 3mg IV Q8H dehydration
- Multiple occurrence at home - Multiple occurrences at home - father asked about the effects
- Created a fluid imbalance and in ED of dehydration on vital signs
- Solid foods encouraged if she - Mom explains that patient gets - Both parents would only feed
could tolerate them very upset when she vomits this child baby food
- Zofran was effective - Parents needed encouraged to
- Did not throw up once admitted give patient water frequently
- CO2 and BUN levels abnormal - Parents wanted to know the
most effective ways to battle
dehydration with out IV
therapy
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Step 3: Draw lines between related problems. Number boxes as you prioritize problems.
LASTLY- label the problem with a nursing diagnosis.

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes
Problem # ____1___:
General Goal: maintain a normal electrolyte balance

Predicted Behavioral Outcome Objective (s): The patient will……

Have Na, K, Cl, CO2 levels in normal ranges and be free of symptoms of imbalance on the day of care.

Nursing Interventions Patient Responses 


1. IV fluids 1. Labs normalized
2. Pt ate 4 tubs of baby food 2. Did not have diarrhea or vomiting
3. Administer Zofran 3. To prevent vomiting
4. Encourage fluids by mouth 4. 2oz was intake (water)
5. Monitor I&O every hour 5. I: about 10 oz, O: 1 wet diaper
6. IV assessment QH when infusing 6. Pt did well with IV assessment
7. Educate parents about condition, 7. Parents were involved and
and how to help compliant in care
8. Distraction during IV removal 8. Patient did not hyperventilate

Evaluation of outcome objectives:

Outcome met - patient was free of late imbalance symptoms and labs remained normal

Problem # ____2___:
General Goal: maintain adequate hydration

Predicted Behavioral Outcome Objective (s): The patient will……

Not vomit on the day of care.

Nursing Interventions Patient Responses

1. Administer Zofran 3mg IV Q8H 1. Did not have an increase in N/V

2. Pt comforted to prevent vomiting 2. Pt responded well to mom’s touch
3. Bland diet 3. It prevented vomiting
4. Play on iPad 4. Distracted patient
5. Using a soft and gentle tone 5. Help make pt comfortable in hospital
6. Bedrest / up as tolerated 6. Prevent pt from vomiting while up
7. Monitor I+O QH 7. Pt was compliant in staying hydrated

Evaluation of outcome objectives:

Outcome met, patient did not throw up on the day of care
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Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # ____3___:
General Goal: Formed, solid stool

Predicted Behavioral Outcome Objective (s): The patient will…

Not have diarrhea on the day of care.

Nursing Interventions Patient Responses 


1. Feed solid, low fiber diet 1. Patient only wanted baby food
2. Monitor bowel sounds 2. Normoactive bowel sounds
3. Assess abdomen 3. Pt ok with assessment when mom is present

4. Contact isolation 4. Pt did not mind.

5. Monitor I+O 5. Ate baby food and water
6. Assess skin turgor 6. Monitor for further dehydration
7. Encourage oral intake 7. Occasionally sipped when told
8. Ed. Parents on s/s of dehydration 8. Parents active in patient’s care
and late imbalances

Evaluation of outcome objectives:

Patient did not have diarrhea on day of care

Problem #4
General goal : parents will understand S/S of dehydration

Predicted Behavioral Outcome Objective (s): The parents will……

Repeat S/S of dehydration to me on the day of care.

Nursing Interventions Patient Responses

1. Ed. parents of causes of N/V/D 1. were receptive and active in education

2. Ed. about 3 severities of dehydration 2. Pt cannot understand her status d/t age
3. Answer parents questions 3. Dad understood HR can incre. w/ dehydration
4. Ed. Parents about dehydration assessment 4. Were interested in VS and skin turgor
5. Explain why I&O monitoring is important 5. They let me know everything the child ate and
how many diapers she dirtied
6. Stressed S/S of dehydration 6. Said they would return if pt became fatigued,
not eating, or drinking
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7. Ed. Dehydration occurred due to N/V/D from 7. Parents verbally said this back to me later in
gastroenteritis day
8. Treating gastroenteritis will help prevent 8. Parents understood, stating they will finish
Further dehydration antibiotics tx

Evaluation of outcome objectives:

Parents were able to identify S/S of dehydration before they were discharged

Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # ____5___:
General Goal: decrease patient’s fear of health care professionals

Predicted Behavioral Outcome Objective (s): The patient will……

Not grind teeth and tense muscles on the day of care.

Nursing Interventions Patient Responses 


1. Use positive reinforcement w/ all 1. Pt sometimes smiled back
nursing care 2. Pt was less anxious the more I talked to
2. Talk softly and kindly her
3. Talk with mom before talking with pt 3. Gained a little bit of trust from the pt
4. Do all assessments while mom is 4. Pt was least tense when mom held her
holding pt
5. Try to make distractions from IV
5. Pt likes playing on her ipad and funny
therapy noises
6. Offer pt ice cream or treat after ice- 6. Pt likes icecream, would try to behave for
cream removal ice cream
7. Soothe pt while she got her BP done. 7. Soothing worked best when coming from
8. Night nurse administered Benadryl to mom
help her fall asleep 8. Pt slept through the night

Evaluation of outcome objectives:

Outcome half met. Pt did not grind teeth but did tense muscles when she saw health care professionals.
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Problem # ____6__:
General Goal: to help increase weight

Predicted Behavioral Outcome Objective (s): The patient will……

Eat something other than baby food on the day of care

Nursing Interventions Patient Responses 


1. Encourage pt to eat solid foods 1. She was not interested
2. Ed. Parents that their child needs 2. Parent listen to me but did not act on it
more nutrients 3. Pt had trouble understanding me
3. Talk with pt with small words to 4. Baby food, jello, and ice cream were
encourage trying new foods easiest to find
4. Search unit for foods patient may like 5. Pear was pt’s favorite flavor of baby
5. Ask parents what ind of baby food food
flavors she likes 6. About 4 tubs of baby food eaten.
6. Monitor I&O 7. Patient was meeting requirements with
7. Make sure child is getting fluid oral and IV intake
requirements

Evaluation of outcomes : outcome not

met. Pt only ate baby food and parents
would not encourage her to eat anything
else.