Nursing Diagnosis and Care Plan
Guidelines for Course Project Milestone 2:
Nursing Diagnosis and Care Plan Assignment
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 developa nursing care plan.
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)
This assignment is worth a total of 250 points.
The assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MTat 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.
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.
Save the file by clicking “Save as” and adding your last name to the file name, e.g., “NR305_Milestone2_Form_Smith”
Please post questions in the weekly Q&A Forums so the entire class may view the answers.
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.
Assignment Criteria A
Outstanding or highest level of performance
Very good or high level of performance
Competent or satisfactory level of performance
Poor or failing or unsatisfactory level of performance
Analyze the Data
Areas for focused assessment
Identifies all strengths and weaknesses
Overlooks no more than 1 strength and/or 1 weakness
Overlooks morethan 1 strength and 1 weakness
Overlooks more than 2 strengths and 2 weakness areas; item not included
Uses textbook (cites source) to validate all traits identified as strengths
Uses textbook (cites source) to validate all but 1 trait identified as a strength
Uses source to validate strengths, but not the textbook
Does not validate identified strengths
Areas of concern
Uses textbook (cites source) to validate all traits identified as concerns
Uses textbook (cites source) to validate all but 1 trait identified as a concern
Uses source to validate concerns, but not the textbook
Does not validate identified concerns
Health teaching topics
Identifies all areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)
Identifies all but 1-2 knowledge deficits contained in Health History; validates findings using textbook (cites source)
Fails to identify 3 areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)
Does not validate findings with textbook
Nursing Care Plan
Diagnosis properly writtenin NANDA termsand reflects an illness, risk for illness or a wellness diagnosis.
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 termsand does not reflect an illness, risk for illness or wellness diagnosis.
Diagnosis is not documented
Goal realistic; outcome measurable and timed. Cultural considerations are identified and addressed.
Goal realistic but outcome not measurable or timed. Cultural considerations are mostlyaddressed
Goal somewhat realistic; outcome not measurable or timed. Cultural considerations are barely addressed.
Goal is not documented; cultural considerations are not adequately addressed
Interventions will aid in achievement of outcome; sound, rationale provided
Interventions will aid in achievement of outcome; rationale provided but not necessarily sound
Interventions incomplete and rationale provided but not necessarily sound
Interventions will not support outcome achievement; no rationale provided
Criteria listed to thoroughly evaluate effectiveness of health education
Criteria listed mostly evaluates effectiveness of health education
Criteria listed partially evaluates effectiveness of health education
No evaluation criteria listed
CLARITY OF WRITING
No grammar, spelling, or syntax errors. Writes logically in complete sentences.
No more than 2 errors of any type
2-3 errors of any type
3 or more errors of any type
Total Points Possible = 250 points
D’Amico, Donita, and Colleen Barbarito. Health & Physical Assessment in Nursing, 2nd Edition.Pearson Learning Solutions, 2010.VitalBook file.