PROBLEM‐BASED CARE PLAN EXAMPLES
The following are examples of how a student may complete a Problem‐Based Care Plan using Lippincott Advisor. These examples can be used when creating a care plan for a patient in the clinical setting, while working through a vSim, and incorporating case‐based learning such as an Interactive Case Study.
In this example, the student is working through a case study provided by the instructor. The patient is a 78‐year‐old male admitted for shortness of breath due to a medical diagnosis of heart failure. The student receives the patient’s history and assessment findings to include activity intolerance, but with clear lung sounds and edema to lower extremities. The student is required to create a care plan for this patient. One example uses a traditional care plan with a linear approach and the second example uses a concept map.
Please note these examples are for demonstration purposes. They provide potential responses.
TRADITIONAL CARE PLAN EXAMPLE
| Problem-Based Care Plan Worksheet |
| WHAT ASSESSMENT DATA DOES THE NURSE FIND AS PERTINENT (RECOGNIZE CUES)? |
| Increase in RR and work of breathing while ambulating to the bathroom
Drop in O2 sats from 95% to 89% on RA while ambulating |
| WHAT IS THE DISEASE PROCESS CAUSING THESE ASSESSMENT FINDINGS (ANALYZE CUES)? |
| The patient has an enlarged heart so it cannot pump oxygen to the body on exertion.
There is an imbalance between supply and demand. Lippincott Advisor Diseases and Conditions |
| WHAT IS THE MAIN PROBLEM WITH THE PATIENT THE NURSE CAN TREAT (PRIORITIZE HYPOTHESES)? |
| Activity Intolerance
Lippincott Advisor Problem‐Based Care Plans |
| WHAT IS THE GOAL FOR THE PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? CREATE SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, AND TIMEABLE (SMART) OUTCOMES. |
| The patient will exhibit tolerance for increased physical activity by the end of the shift.
Lippincott Advisor Problem‐Based Care Plans |
| WHAT INTERVENTIONS WILL THE NURSE IMPLEMENT WHEN CARING FOR THIS PATIENT (GENERATE SOLUTIONS & TAKE ACTION)? INCLUDE THE EVIDENCE. LIST INTERVENTIONS IN ORDER OF PRIORITY. INCLUDE COLLABORATIVE AND NURSE‐INITIATED INTERVENTIONS. |
| · Provide supplemental oxygen as ordered and monitor the patient’s response. Lippincott Advisor Problem‐Based Care Plans Rationale: Oxygen therapy helps meet the increased myocardial workload as the heart tries to compensate. Administering oxygen helps to meet cellular needs. Lippincott Advisor Diseases and Conditions > Procedures
· Assess patient’s cardiopulmonary response to activity Lippincott Advisor Problem‐Based Care Plans · Instruct the patient on exercises to increase strength and endurance. Advance activity, as tolerated. Lippincott Advisor Problem‐Based Care Plans Collaborate with Physical Therapy Lippincott Advisor Problem‐Based Care Plans |
| HOW WILL THE NURSE EVALUATE THE PATIENT’S RESPONSE (EVALUATE OUTCOMES)? AND WHAT WAS THE PATIENT’S RESPONSE TO THE INTERVENTIONS? |
| Monitoring the patient’s oxygen saturation when ambulating. Observe for signs and symptoms of distress while ambulating. Assess the need for oxygen.
Communicate with physical therapy about recommendations and their assessment findings |
| WHAT OTHER PROBLEMS COULD THE NURSE LINK TO THIS PATIENT PROBLEM? |
| Fluid overload Lippincott Advisor Diseases and Conditions |
CONCEPT MAP