NIGHTINGALE COLLEGE

DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET

NURSING PROCESS TEMPLATE:

Assessment (Recognizing Cues) Vital signs: Fevers can indicate infection and/or
inflammation. Low oxygen saturation levels (< 90%) can
Which patient information is relevant? What patient data is most
indicate inflammation in the airways. Heart rate and
important? Which patient information is of immediate concern?
respirations: Tachycardia and tachypnea are both signs of
Consider signs and symptoms, lab work, patient statements, H & P,
and others. Consider subjective and objective data.
an inflammatory response in the airways, or asthma.

Lung sounds: Wheezing can indicate a partially blocked

airway or swollen bronchiole tubes from inflammation
(Cleveland Clinic, 2020b). This client had inspiratory and
expiratory wheezes, telling us that he had inflammation
in his bronchiole tubes.

Medical History: 5-year-old boy with a history of asthma

and currently has a fever. Caregiver reports that inhaler
has not been helping.
One condition that is consistent with the cues is severe
Analysis (Analyzing Cues)
acute asthma exacerbation. Another is that the client
Which patient conditions are consistent with the cues? Do the cues
may have a respiratory tract infection. Because of these
support a particular patient condition? What cues are a cause for
concern? What other information would help to establish the conditions, the bronchioles have become inflamed, and
significance of a cue? the client has classic symptoms of an asthma
exacerbation: tachypnea, tachycardia, diaphoresis,
wheezing, shortness of breath, and chest tightness
(Jafarnejad & Khoshnezhad, 2020).
The client is most likely suffering from an asthma attack,
Analysis (Prioritizing Hypotheses)
which includes inflammation and narrowing of airways.
What explanations are most likely? What is the most serious
This could be related to a respiratory infection affecting
explanation? What is the priority order for safe and effective care?
the airways. The most serious explanation at this time
would be a severe asthma attack affecting the client’s
ability to breathe. The priority for safe and effective care
for this client would include maintaining patent airways
and an adequate oxygen saturation level.
Planning (Generate Solutions) Achieve and maintain control of symptoms: medications,
fluids, oxygen.
What are the desirable outcomes? What interventions can achieve
these outcomes? What should be avoided? (SMART Planning- specific,
measurable, attainable, realistic/relevant, time-restricted- Goal Prevent respiratory decline: monitor client for any
setting) indication of decline and treat as necessary.

Avoid dehydration, respiratory irritants, missing

medications, excessive physical activity during acute
exacerbation.
Positioning the client in a high-fowlers or semi-fowlers
Implementation (Take actions)
can help with dyspnea while undergoing nebulizer
How should the intervention or combination of interventions be
therapy (Chanif & Prastika, 2019).
performed, requested, communicated, taught, etc.? What are the
priority interventions? (Mark with asterisk)
Offer the client water to help thin secretions and hydrate.
Some clients may experience a dry mouth from
corticosteroids (Hira et al., 2015). Water can also be
 soothing since the client has a slight fever and is feeling
warm.

Client (and caregiver) education. This client is only 5 years

old so it can be helpful to show him how to properly use
his inhaler (with a chamber) by demonstrating on a
stuffed animal or inanimate object (LaRue & Kelly, 2015).
The caregiver should be educated on the medication
regimen, as well as how to use the inhalers and nebulizer
treatments. We should teach her the importance of the
treatments and when to call the provider. It is important
to inform her of common irritants such as being exposed
to smoke, dust, and pets (National Asthma Council,
2022).

Therapeutic communication: Since this is a pediatric

client, earning his trust can be tough but very important
so that he will feel safe with us and be more likely to
comply with the treatment. We must ask permission
before performing examinations and explain the process
as well as what he can expect.

Offer to turn on a movie or music for him. We want the

client to stay calm, comfortable, and happy. The
distraction of the television may help him rest and feel
more comfortable in such a stressful situation and
setting, being away from home (Children’s Hospital of
Pittsburgh, 2022).
Before the assessment in the ED the client was not using
Evaluation (Evaluating Outcomes)
the spacer and was inhaling too fast (the client should
What signs point to improving/declining/unchanged status? What
take a slow, deep breath). The nurse identified lack of
interventions were effective? Are there other interventions that
could be more effective? Did the patient’s care outlook or status
coordination between activating the inhaler and initiating
improve? the deep breath, angling the inhaler to spray the tongue
or side of the mouth, and the client failing to hold his
breath for 10 seconds after inhalation. If this kind of
management continues, client will not get the necessary
medication he needs when another attack occurs.

Client’s cough has subsided and has been able to relax

without breathing difficulty. Oxygen saturation improved
to 96%. Client’s heart rate and respiratory rate have
dropped to WNL. Intermittent expiratory wheezes still
present but diminishing.

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Patient Information (SBAR)
Main Concept
S: 5-year-old boy with an apparent acute (Should be focus of below map)
severe exacerbation of asthma.
B: The client was alert and speaking in short INFLAMMATION
sentences due to shortness of breath.
Inspiratory and expiratory wheezes audible
without the use of a stethoscope. Fever of
100.4 F, HR of 130 bpm, RR 40 bpm, O2 sat
of 90%. Disease Process/Pathophysiology/Risk Factors
A: I think the patient is experiencing asthma
exacerbation possibly due to respiratory
illness. Asthma is an airflow obstruction due to bronchial
R: I recommend starting nebulizer hyperresponsiveness and underlying inflammation. The
treatments and would like you to come place bronchoconstriction quickly occurs to narrow the
orders as soon as possible, please. airways due to stimuli such as irritants, allergens, or
infection. During an exacerbation, the epithelial cells
that line the airway initiate an inflammatory response,
causing the airways to become inflamed and begin to
swell and narrow. The muscles around the airway
Recognizing Cues, (S&S)
contract and produce more mucus which leads to
further narrowing of the bronchial tubes.
• Respiratory rate – 40 bpm
• Low oxygen saturation - 90% • Step 1 – Mild intermittent asthma. Symptoms
• Fever - 100.4 F fewer than two times a week.
• Chest tightness • Step 2 – Mild persistent asthma. Symptoms
more than two times a week, but no more
• Inspiratory and expiratory wheezes
than once a day.
• Rapid heart rate – 130 bpm • Step 3 – Moderate persistent asthma.
Symptoms every day.
• Step 4 – Severe persistent asthma. Constant
symptoms.

Analyzing Cues/Concerns Risk Factors: Allergies, family history,

secondhand smoke, environmental exposures,
more prevalent in children
Supporting connections between the cues
(S&S) and the client condition:

• Wheezing indicates bronchiole

inflammation causing airway
Prioritizing Hypotheses
constriction.
• Dyspnea (shortness of breath) Prioritize client conditions and care:
causes tachypnea and tachycardia.
• Hypoxia (low oxygen saturation) is 1. Wheezing/dyspnea: Relieve airway constriction -
related to the impaired gas establish and maintain patent airway.
exchange due to the airway 2. Hypoxia: Supplement with oxygen to increase
constriction. oxygen saturation.
• Fever is related to suspected
respiratory infection. 3. Fever: Treat respiratory illness.
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 Generate Solutions/Outcomes/Interventions
SMART Planning Taking Action – (How To)

1. Within 30 minutes of treatment and 1. Apply nasal cannula and titrate oxygen to
application of supplemental oxygen via nasal maintain oxygen saturation >95%.
cannula, client will obtain and maintain oxygen
saturation levels >95%. 2. Administer medications/breathing treatments
2. Within 30 minutes of treatment, respiratory as directed to decrease inflammation and
rate will be within 20-30 bpm and heart rate will wheezing. Listen to lungs every 30 minutes x2
be within 75-115 bpm. hours to assess for wheezing.

3. By end of the shift, client will have improved 3. Position the client in a high-fowlers or semi-
airway clearance as evidenced by clear lung fowlers position to maintain airway clearance.
sounds in all 4 lung fields anteriorly and
posteriorly. 4. Administer antipyretic medication as needed
to decrease fever and provide comfort.
4. By end of the shift, client’s temperature will
be decreased from 100.4 F down to <99 F
5. Educate the client and caregiver regarding plan
following medication administration.
of care, medications, and inhaler use. Verbalize
5. By end of shift, client will correctly and demonstrate correct spacer use and
demonstrate the use of inhaler spacer three educate on importance of proper use.
times, as a result of proper client and caregiver
education.

Evaluating Outcomes

1. The client’s O2 saturation was 98% on room air without evidence of dyspnea or chest tightness following
oxygen therapy.
2. Client’s respiratory rate decreased to 24 bpm and heart rate decreased to 100 bpm. Client verbalized ease of
breathing. Mild intermittent expiratory wheezes audible only with stethoscope.
3. Client able to sit upright to expectorate mucus and maintain airway clearance. Lungs clear with intermittent
expiratory wheezes.
4. Client’s temperature decreased from 100.4 F to 98.9 F by end of shift.
5. Caregiver and client demonstrated the appropriate use of inhaler with spacer, ensuring client inhales the
amount of medication needed, optimizing the effectiveness of the medication.

6.

4.

5.
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 References

Children’s Hospital of Pittsburgh. (2022). Distraction techniques | Children’s Hospital Pittsburgh.

https://www.chp.edu/our-services/radiology/our-approach/distractiontechniques

Cleveland Clinic. (2020b). Wheezing: Definition, causes & treatment.

https://my.clevelandclinic.org/health/symptoms/15203-wheezing

Giddens, J. F. (2017). Concepts for nursing practice (2nd ed.). Elsevier.

Jafarnejad, S., & Khoshnezhad Ebrahimi, H. (2020). Clinical guidelines on pediatric asthma exacerbation in emergency

department, a narrative review. European journal of translational myology, 30(1), 8682.

https://doi.org/10.4081/ejtm.2019.8682

National Asthma Council. (2022). The National Asthma Council Australia. https://www.nationalasthma.org.au/living-

with-asthma/resources/patientscarers/factsheets/pets-and-allergies

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