Problem Based Care Plan – CJMM_NCLEX NG (2).pdf Download Problem Based Care Plan – CJMM_NCLEX NG (2).pdf(PBCP)
-REMEMBER-per your Rubric—

1. Identifies at least 3 critical cues that are relevant and could impact patient condition. (requires 3 copies of PBCP)-2 actual diagnosis (one physiological and one psychosocial) and one at risk.

2. Able to make 3 -4 supporting connections between the cues and patient conditions, supporting a particular patient condition,

3. Able to identify 2 cues of concern to patient outcome

4. Able to determine the order of 3 hypotheses critical to positive patient outcomes listing them in order.

5. List 5 solutions/outcomes with appropriate interventions that will positively impact patient outcome and are appropriate to the care of the patient. Listing 1 avoiding outcome that will negatively impact patient can also be listed in this category. Clearly identify the negative outcome(s) and what shouldn’t be carried out and why. All outcomes/ goals are SMART

6. Describing how each of the 5 interventions will be carried out, performed, administered, communicated, taught etc. Priority interventions are identified correctly.

7. Describe how the 5 interventions were effective, improved patient outcome, and why. Or describe what interventions didn’t work and what should be done instead in the future. What would you do differently? How would the intervention adversely affect the patient outcome or care?

Rubric
Care Plan
Care Plan
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeData Collection
(Pgs. 4.22, 4.23, 4.24)
12.5 to >8.6 pts
Full Marks
Thoroughly addresses all information on pages 4.22-4.24
8.6 to >4.6 pts
Acceptable Expectations
4 or more aspects of pertinent data missing
4.6 to >0.0 pts
Minimal/Needs Improvement
8 or more aspects of pertinent data missing
0 pts
No Marks
12 or more aspects of pertinent data missing. Incomplete data provided
12.5 pts
This criterion is linked to a Learning OutcomeDisease Process/Pathophysiology Risk Factors
12.5 to >8.6 pts
Full Marks
Thorough review of the disease process pathophysiology. Identifies risk factors.
8.6 to >4.6 pts
Acceptable Expectations
Missing thorough review or risk factors missing.
4.6 to >0.0 pts
Minimal/Needs Improvement
Critical aspects of pathophysiology missing.
0 pts
No Marks
Incomplete review of pathophysiology, risk factors not identified.
12.5 pts
This criterion is linked to a Learning OutcomeRecognizing Cues
12.5 to >8.6 pts
Full Marks
Identifies at least 4 critical cues that are relevant and could impact patient condition.
8.6 to >4.6 pts
Acceptable Expectations
Identifies 2-3 critical cues that are relevant and could impact patient condition.
4.6 to >0.0 pts
Minimal/Needs Improvement
Identifies one critical cue, missing critical cues essential to positi8ve patient outcomes.
0 pts
No Marks
Missing all critical cues; negatively affecting patient outcome.
12.5 pts
This criterion is linked to a Learning OutcomeAnalyzing Cues
12.5 to >8.6 pts
Full Marks
Able to make 3 -4 supporting connections between the cues and patient conditions, supporting a particular patient condition, Able to identify 2 cues of concern to patient outcome
8.6 to >4.6 pts
Acceptable Expectations
Able to make 1- 2 supporting connections between the cues and patient conditions, Able to identify one cue of concern to patient outcome
4.6 to >0.0 pts
Minimal/Needs Improvement
Can make one supporting connection between cue and patient condition or one cue of concern
0 pts
No Marks
Not able to make any supporting connections between cue and patient condition or any cues of concern
12.5 pts
This criterion is linked to a Learning OutcomePrioritizing Hypotheses
12.5 to >8.6 pts
Full Marks
Able to determine the order of 3 hypotheses critical to positive patient outcomes listing them in order
8.6 to >4.6 pts
Acceptable Expectations
Able to determine the order of 2 hypotheses critical to patient outcomes listing them in order
4.6 to >0.0 pts
Minimal/Needs Improvement
Able to list one hypothesis
0 pts
No Marks
No critical hypothesis listed
12.5 pts
This criterion is linked to a Learning OutcomeGenerating Solutions
12.5 to >8.6 pts
Full Marks
List 5 solutions/outcomes with appropriate interventions that will positively impact patient outcome and are appropriate to the care of the patient. Listing 1 avoiding outcome that will negatively impact patient can also be listed in this category. Clearly identify the negative outcome(s) and what shouldn’t be carried out and why. All outcomes/ goals are SMART
8.6 to >4.6 pts
Acceptable Expectations
List 3-4 solutions with appropriate interventions that will positively impact patient. Listing 1 outcome that will negatively impact patient and should be avoided. Clearly identify the negative outcomes and why they shouldn’t be carried out and why. All Goals are SMART
4.6 to >0.0 pts
Minimal/Needs Improvement
List 1-2 solutions with appropriate interventions that will positively impact patient OR Not listing any negative outcome solutions or interventions to avoid.
0 pts
No Marks
Listing no solutions or outcomes that will positively impact the patient outcome. Listing no solutions that will negatively affect the patient
12.5 pts
This criterion is linked to a Learning OutcomeTaking Action
12.5 to >8.6 pts
Full Marks
Describing how each of the 5 interventions will be carried out, performed, administered, communicated, taught etc. Priority interventions are identified correctly.
8.6 to >4.6 pts
Acceptable Expectations
Describing how 3 interventions will be carried out, performed, administered, communicated, taught etc.
4.6 to >0.0 pts
Minimal/Needs Improvement
Describing how 1 intervention will be carried out, performed, administered, communicated, taught etc.
0 pts
No Marks
Not describing how any interventions will be performed or carried out.
12.5 pts
This criterion is linked to a Learning OutcomeEvaluating Outcomes
12.5 to >8.6 pts
Full Marks
Describe how the 5 interventions were effective, improved patient outcome, and why. Or describe what interventions didn’t work and what should be done instead in the future. What would you do differently? How would the intervention adversely affect the patient outcome or care?
8.6 to >4.6 pts
Acceptable Expectations
Describe how the 3 interventions were effective, improved patient outcome, and why. Or describe what didn’t work and what should be done instead in the future. What would you do differently? How would the intervention adversely affect the patient outcome or care?
4.6 to >0.0 pts
Minimal/Needs Improvement
Describe how 1 intervention was effective, improved patient outcome, and why. Or describe what didn’t work and what should be done instead in the future. What would you do differently? How the intervention adversely affected the patient outcome or care?
0 pts
No Marks
Did not discuss the outcomes and interventions
12.5 pts
This criterion is linked to a Learning OutcomeCare Plan Prep (50 points)
-Patho and Health History (10pts)
-Medication Reconciliation and Teaching (10pts)
-Nursing Diagnoses, Interventions and Goals (10pts)
-Labs and Diagnostic (10pts)
-Fall Risk, Braden Score, Nutrition Assessment and Rounding (10pts)
50 pts
Full Marks
-Patho and Health History (10pts) -Medication Reconciliation and Teaching (10pts) -Nursing Diagnoses, Interventions and Goals (10pts) -Labs and Diagnostic (10pts) -Fall Risk, Braden Score, Nutrition Assessment and Rounding (10pts)
40 pts
Acceptable Expectations
Missing One
30 pts
Marginal Needs Improvement
Missing two
20 pts
Minimal/Needs Improvement
Missing three
10 pts
Minimal/Needs Improvement
Missing four
0 pts
No Marks
All areas Missing
50 pts
Total Points: 150

The Nursing Process

 Student’s Name

Institutional Affiliation

Course

Instructor’s Name

Date

 

 

The Nursing Process

Introduction

The entire nursing process is described by the acronym ADPIE, which stands for assessment, diagnosis, planning, implementation, and evaluation. This process is normally used in nursing to guide patients’ treatment plans. The ADPIE process can be applied both in physical or mental treatment regardless of the setting or the patients’ characters (Toney-Butler & Thayer, 2021). For instance, this discussion is based on a patient who is suffering from a physical illness. Diagnosis can be performed with the help of the NANDA nursing diagnosis. Therefore, the purpose of this paper is to use the ADPIE and NANDA models to develop a treatment plan for a patient.

Assessment

Patient assessment is the first process, which is often crucial in the ADPIE process. Regarding subjective data, the patient complained of chest tightness, coughing, headache due to high blood pressure. The patient also complains of pain, rated 10 out of 10 on a scale of 0 – 10. The patient also complains of nausea. Additionally, the patient complains of fatigue, shortness of breath, lightheadedness, and sudden dizziness. She also complains of pain and coughing.  Regarding the objective data, the patient experiences cold sweat, weakness, and shortness of breath. The patient also had a persistent cough with white or pinkish mucus.

Also, heart palpitations indicated irregular heartbeats. The patient has a history of high blood pressure, stroke, and smoking lifestyle. Other assessments include imaging tests such as an electrocardiogram (ECG), blood tests, chest x-ray, echocardiogram, and coronary angiography (Crespo‐Leiro et al., 2018). An electrocardiogram (ECG) is an important test in suspected heart attacks. It should be done within 10 minutes of being admitted to the hospital.

Diagnosis

• Acute pain, related to tissue ischemia as evidenced by the statement, “pain rated 10 out of 10 on a scale of 0 – 10,” headache, and nausea.
• Activity intolerance, related to insufficient physiological energy to ensure desired daily activities as evidenced by the patient reporting weakness and fatigue and chest tightening (dyspnea).
• Ineffective coping, related to the inability to form a valid appraisal of the stressors as evidenced by destructive behavior such as excessive smoking.
• Risk for decreased cardiac output as evidenced by continued smoking behavior and chest tightening.

These three diagnoses are related to the patient’s symptoms are discussed in the assessment section. The NANDA nursing diagnosis was used to arrive at the patient’s diagnoses (Nurse.org, 2021). The identified nursing diagnoses consist of three problem-based-focus nursing diagnoses (one is psychological diagnosis) and one risk diagnosis. All the diagnoses should be given the attention they deserve, however, ineffective coping, and risk for decreased cardiac output should be of more concern than the other ones (Crespo‐Leiro et al., 2018). The primary cause of all the other diagnoses and the symptoms the patient is currently undergoing is ineffective coping.

The effects of tobacco smoking on blood pressure are complex. Literature shows that tobacco smoking increases blood pressure acutely and increases the risk of renovascular, malignant, and masked hypertension. The risk of cardiac output reflects aspects of acute decompensating heart failure which is a very dangerous medical condition (Crespo‐Leiro et al., 2018). Chest tightening, pain, and nausea are signs of heart failure which is exacerbated by reduced cardiac output. Therefore, an appropriate treatment plan is needed to improve the patient’s condition.

Planning and Outcomes

Hypotheses

• The patient will no longer suffer from headaches and pain.
• The patient will participate in daily necessary and/or desired activities.
• The patient will stop smoking.

Desired Outcomes

• Pain to reduce to a rate below 5 out of 10 on a scale of 0-10, within four hours of intervention.
• Maintain blood pressure within the normal range in less than 7 days.
• Walk 30 minutes a day, 5 days a week.
• Avoid smoking within the first 4 weeks of intervention.
• Improved muscle strength and reduced fatigue in 4 weeks.

Intervention

The five interventions include:

• Monitor and record blood pressure.
• Provide measures to relieve pain before it comes more severe.
• Monitor physiologic response to activity; adjust accordingly
• Refer the patient to a substance abuse support group and mental health team for tobacco cessation.
• Administer medications as prescribed, noting side effects and toxicity
• Educate patients on the need for and how to incorporate lifestyle changes

These interventions are related to each one of the four diagnoses above. The first intervention is to monitor and record the patient’s blood pressure regularly. The patient has a history of blood pressure. The patient’s blood pressure is elevated and she is experiencing headaches due to high blood pressure. This intervention will address the risk for cardiac output, acute pain, and activity intolerance (Crespo‐Leiro et al., 2018). Both pharmacologic and non-pharmacologic measures for pain management will be applied. Since it is severe pain, an opioid can be administered and titrated in ATC scheduled doses until the pain is relieved. Non-pharmacologic measures such as physical, cognitive-behavioral strategies, and lifestyle pain management will be applied.

Monitoring physiologic response to activity and adjusting appropriately will help manage intolerance to physical activity. The nurse can assess physiological parameters, such as vital signs (pulse, temperature, blood pressure, and respiratory rate), which are sensitive and specific for predicting the potential for adverse outcomes (Crespo‐Leiro et al., 2018). The patient will be referred to mental health professionals and support groups for tobacco cessation. Both individual and group counseling can be effective to support the patient through the cessation process. All medications to improve breathing, reduce pain, improve cough, manage blood pressure, and others will be administered per the physician’s instruction (Crespo‐Leiro et al., 2018). Patient education will take one week on medication adherence and lifestyle changes to improve the patient’s condition.

Evaluation

After the interventions, a plan evaluation was carried out to determine whether the goals were met. Most of the goals or outcomes of this care plan were achieved. For example, pain reduced to 4 out of 10 within the four hours of intervention (Crespo‐Leiro et al., 2018). Blood pressure was also maintained and returned to a normal range within 5 hours of intervention. Additionally, the patient was able to walk 30 minutes a day for 5 days. the patient gained muscle strength, headache and chest tightness reduced, nausea, and cough improved. However, the patient has not quit smoking (Crespo‐Leiro et al., 2018). She reports smoking 3 cigarettes a week for the past two weeks, which is an improvement. The patient should continue with cessation counseling.

Conclusion

ADPIE reflects the nursing process, which stands for assessment, diagnosis, planning, intervention, and evaluation. NANDA nursing diagnosis helps nurses determine the exact condition of patients. This paper has established the whole nursing process for the selected patient. The outcomes of this care plan were met and the patient’s condition improved.

References

Crespo‐Leiro, M. G., Metra, M., Lund, L. H., Milicic, D., Costanzo, M. R., Filippatos, G., … & Ruschitzka, F. (2018). Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. European journal of heart failure, 20(11), 1505-1535. https://doi.org/10.1002/ejhf.1236

Nurse.org. (2021). The 2021 nursing diagnosis guide. https://nurse.org/resources/nursing-diagnosis-guide/

Toney-Butler, J. & Thayer, M. (2021). Nursing Process. https://www.ncbi.nlm.nih.gov/books/NBK499937/