Nursing Diagnosis and Care Plan Assignment
Purpose This activity will be a continuation of the Milestone 1: Health History that you submitted in Week 4. In this part of the assignment you will take the information you gathered, analyze the data, and develop a nursing care plan. Course Outcomes This assignment enables the student to meet the following course outcomes: CO #3: Utilize effective communication when performing a health assessment. (PO #3) CO #4: Identify teaching/learning needs from the health history of an individual. (PO #2) CO #5: Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation. (PO #6) Points This assignment is worth a total of 250 points. Due Date The assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 6.Post questions to the weekly Q & A Forum. Contact your instructor if you need additional assistance.See the Course Policies regarding late assignments. Failure to submit your paper to the Dropbox on time may result in a deduction of points. Directions 1. Download the NR305_Milestone2_Form from Doc Sharing. You will type your answers directly into this Word document. Your paper does NOT need to follow APA formatting; however, you are expected to use correct grammar, spelling, syntax and write in complete sentences. 2. Save the file by clicking “Save as” and adding your last name to the file name, e.g., “NR305_Milestone2_Form_Smith” 3. Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 6. Please post questions in the weekly Q & A Forums so the entire class may view the answers. Grading Criteria Category Points % Description ANALYZE THE DATA Areas for focused assessment 30 12 Provide an overview of those areas of strength and weakness noted on the Health Assessment, Health History. Do not go into detail in this section. Client’s strengths 30 12 Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook. Areas of concern 30 12 Expand on areas previously identified as abnormal and those that place the person at health risk. Support your observations with data from the textbook. Health teaching topics 30 12 What health education needs have you identified? Support your statements with facts from the Health History and information from your textbook. NURSING CARE PLAN Diagnosis 30 12 Write one nursing diagnosis that reflects a priority need for this person. Types of diagnoses include an illness, risk for illness or a wellness diagnosis. Plan 30 12 Write one goal and one measurable expected outcome related your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural consideration of the client. For example, African Americans are at higher risk for hypertension and any prehypertensive blood pressure readings should be addressed. Intervention 30 12 Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed Evaluation 30 12 You won’t have an opportunity to carry out your care plan so you cannot evaluate the effectiveness of your nursing orders/interventions. Instead comment on what you would look for in order to evaluate your effectiveness CLARITY OF WRITING 10 4 Use proper grammar, spelling and medical language Total 250 pts 100% A quality paper will meet or exceed all of the above requirements. Grading Rubric Assignment Criteria A Outstanding or highest level of performance B Very good or high level of performance C Competent or satisfactory level of performance F Poor or failing or unsatisfactory level of performance Analyze the Data Areas for focused assessment 30 points Identifies all strengths and weaknesses 27-30 points Overlooks no more than 1 strength and/or 1 weakness 25-26 points Overlooks more than 1 strength and 1 weakness 22-24 points Overlooks more than 2 strengths and 2 weakness areas; item not included 0-21 Client’s strengths 30 points Uses textbook (cites source) to validate all traits identified as strengths 27-30 points Uses textbook (cites source) to validate all but 1 trait identified as a strength 25-26 points Uses source to validate strengths, but not the textbook 22-24 Does not validate identified strengths 0-21 Areas of concern 30 points Uses textbook (cites source) to validate all traits identified as concerns 27-30 points Uses textbook (cites source) to validate all but 1 trait identified as a concern 25-26 points Uses source to validate concerns, but not the textbook 22-24 Does not validate identified concerns 0-21 Health teaching topics 30 points Identifies all areas of knowledge deficit contained in Health History; validates findings using textbook (cites source) 27-30 points Identifies all but 1-2 knowledge deficits contained in Health History; validates findings using textbook (cites source) 25-26 points Fails to identify 3 areas of knowledge deficit contained in Health History; validates findings using textbook (cites source) 22-24 Does not validate findings with textbook 0-21 Nursing Care Plan Diagnosis 30 points Diagnosis properly written in NANDA terms and reflects an illness, risk for illness or a wellness diagnosis. 27-30 points Diagnosis not written in NANDA terms or does not reflect an illness, risk for illness or a wellness diagnosis.25-26 points Diagnosis not written in NANDA terms and does not reflectan illness, risk for illness or wellness diagnosis. 22-24 Diagnosis is not documented 0-21 Plan 30 points Goal realistic; outcome measurable and timed. Cultural considerations are identified and addressed. 27-30 points Goal realistic but outcome not measurable or timed. Cultural considerations are mostly addressed 25-26 points Goal somewhat realistic; outcome not measurable or timed. Cultural considerations are barely addressed. 22-24 Goal is not documented; cultural considerations are not adequately addressed 0-21 Intervention 30 points Interventions will aid in achievement of outcome; sound, rationale provided 27-30 points Interventions will aid in achievement of outcome; rationale provided but not necessarily sound 25-26 points Interventions incomplete and rationale provided but not necessarily sound 22-24 Interventions will not support outcome achievement; no rationale provided 0-21 Evaluation 30 points Criteria listed to thoroughly evaluate effectiveness of health education 27-30 points Criteria listed mostly evaluates effectiveness of health education 25-26 points Criteria listed partially evaluates effectiveness of health education 22-24 No evaluation criteria listed 0-21 CLARITY OF WRITING 10 points No grammar, spelling, or syntax errors. Writes logically in complete sentences. 10 points No more than 2 errors of any type 8-9 points 2-3 errors of any type 6-7 points 3 or more errors of any type 0-5 points Total Points Possible = 250 points Course Project Milestone #2: Nursing Diagnosis and Care Plan Form Your Name: Date: Your Instructor’s Name: Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling and medical language. Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone2_Form_Smith” When you are finished, submit the form to the Milestone 2 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment. 1: Analyze Assessment Data: Based on the health history information, identify the following: A. Areas for focused assessment (30 points) Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History. B. Client’s strengths (30 points) Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook. C. Areas of concern (30 points) Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the textbook. D. Health teaching topics (30 points) Identify health education needs. Support your statements with facts from the Health History and information from your textbook. 2: Nursing Care Plan Next, plan your care based on your analysis of your assessment data: A. Diagnosis (30 points) Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility. B. Plan (30 points) Write one goal and one measurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural considerations for this client. C. Intervention (30 points) Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed. D. Evaluation (30 points) You will not carry out your care plan so you cannot evaluate the effectiveness of your nursing interventions. Instead, comment on what you would look for in order to evaluate your effectiveness.