Devry NR305 Milestone #2: Nursing Diagnosis and Plan of care

| January 30, 2017

Question
Course Project Milestone 2:

Nursing Diagnosis and Plan of Care

Guidelines and Grading Rubric

Purpose
This activity will be a continuation of the Milestone 1: Health History that you submitted in Week 3. In this part of the assignment you will take the information you gathered, analyze the data, and develop a nursing plan of care.

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 300 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, and 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

15

5

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

10

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

10

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

20

6

What health education needs have you identified? Support your statements with facts from the Health History and information from your textbook.

PHYSICAL EXAMINATION ASSESSMENT

B/P, P, RR

15

5

Describe blood pressure characteristics, quality of pulse and respirations

Respiratory (assess all 5 lobes)

30

10

Ask relevant respiratory history and Review of Systems questions

Ø History of Croup or Asthma? Y— N—

Ø History of wheezing? Y— N—

Ø Noisy breathing? Y— N—

Ø Shortness of breath Y— N—

Ø Chronic cough? Y— N—

Ø Exposure to cigarette smoke or Environmental/Noxious fumes? Y— N—

If yes, explain_________

Ø Most recent TB testing ————–

Ø Last Chest X Ray——————–

Ø Auscultate all lobes for lung sounds and document

Cardiac (relevant cardiac and peripheral vascular history)

30

10

Ask relevant cardiac and peripheral vascular history and review of systems questions

Ø Any congenital heart problems?

Ø Any history of murmur?

Ø Any limitation of activity?

Ø Any dyspnea on exertion?

Ø Any history of palpitations?

Ø Any history of high blood pressure?

Ø Any coldness to extremities noted?

Ø Assess heart sounds and absence or presence of abnormal heart sounds and document

Ø Assess general appearance including skin color and presence of visible pulsations

Inspect neck for visible carotid pulses and jugular venous distention

Ø Inspect legs for edema and note if present

Ø Palpate all pulses, comparing left to right

Ø Test capillary refill, comparing left to right

Abdomen (GI)

Inspect contour and visible pulsations

Auscultate for bowel sounds

30

10

Ask relevant abdominal history and Review of Systems questions, including reproductive health history questions

Ø Any abdominal pain?

Ø Any nausea/vomiting?

Ø Any history of ulcer?

Ø Frequency of bowel movements, stool color and characteristics?

Ø Any history of diarrhea?

Ø History of constipation or stool holding?

Ø Anal itching?

Ø History of pinworms?

Ø Any history of use of laxatives?

Ø Rectal Bleeding

Ø Age of onset of Menses?

Ø Pregnancies, Miscarriages, Abortions?

Ø Auscultate abdominal quadrants for bowel sounds and document

NURSING PLAN OF CARE

Diagnosis

15

5

Write one NANDA-approved 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

10

Write one goal and one measurable expected outcome related to 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 pre-hypertensive blood pressure readings should be addressed.

Intervention

30

10

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

15

5

You won’t have an opportunity to carry out your plan of care 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

300 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

(15 points)

Identifies all strengths and weaknesses

(13-15 points)

Overlooks no more than 1 strength and/or 1 weakness

(11-12 points)

Overlooks more than 1 strength and 1 weakness

(9-10 points)

Overlooks more than 2 strengths and 2 weakness areas; item not included

(0–8 points)

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 points)

Does not validate identified strengths

(0–21 points)

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 points)

Does not validate identified concerns

(0–21 points)

Health teaching topics

(20 points)

Identifies all areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)

(18-20 points)

Identifies all but 1–2 knowledge deficits contained in Health History; validates findings using textbook (cites source)

(16-17 points)

Fails to identify 3 areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)

(14-15 points)

Does not validate findings with textbook

(0–13 points)

Physical Examination Assessment

Vital signs

(15 points)

Identifies characteristics and quality of B/P and pulse. Notes rate and rhythm of respirations.

(13-15 points)

Overlooks no more than 1 characteristic of B/P, pulse and respirations.

(11-12 points)

Overlooks more than 2 characteristic of B/P, pulse and respirations.

(9-10 points)

Overlooks more than 3 characteristic of B/P, pulse and respirations; item not included

(0–8 points)

Respiratory examination

(30 points)

Responds to all health history questions and assesses and documents respiratory sounds in all 5 lobes.

(27–30 points)

Responds to all but 1 health history questions and assesses and documents respiratory sounds in all 5 lobes.

(25-26 points)

Responds to all but 2 health history questions and assesses and documents respiratory sounds in all 5 lobes.

(22-24 points)

Minimal response to health history questions and assesses but does not document respiratory sounds in all 5 lobes.

(0–21 points)

Cardiac examination

(30 points)

Responds to all health history questions and assesses and documents heart sounds.

(27–30 points)

Responds to all but 1 health history questions and assesses and documents heart sounds.

(25-26 points)

Responds to all but 2 health history questions and assesses and documents heart sounds

(22-24 points)

Minimal response to health history questions and assesses but does not document heart sounds.

(0–21 points)

Abdomen examination

(30 points)

Responds to all health history questions and assesses and documents abdomen sounds.

(27–30 points)

Responds to all but 1 health history questions and assesses and documents abdomen sounds.

(25-26 points)

Responds to all but 2 health history questions and assesses and documents abdomen sounds

(22-24 points)

Minimal response to health history questions and assesses but does not document abdomen sounds.

(0–21 points)

Nursing Plan of Care

NANDA Nursing Diagnosis

(15 points)

Diagnosis properly written in NANDA terms and reflects an illness, risk for illness or a wellness diagnosis.

(13-15 points)

Diagnosis not written in NANDA terms or does not reflect an illness, risk for illness or a wellness diagnosis. (11-12 points)

Diagnosis not written in NANDA terms and does not reflectan illness, risk for illness or wellness diagnosis.

(9-10 points)

Diagnosis is not documented

(0–8 points)

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 points)

Goal is not documented; cultural considerations are not adequately addressed

(0–21 points)

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 points)

Interventions will not support outcome achievement; no rationale provided

(0–21 points)

Evaluation

(15 points)

Criteria listed to thoroughly evaluate effectiveness of health education

(13-15 points)

Criteria listed mostly evaluates effectiveness of health education

(11-12 points)

Criteria listed partially evaluates effectiveness of health education

(9-10 points)

No evaluation criteria listed

(0–8 points)

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

(7 points)

3 or more errors of any type

(0–6 points)

Total Points Possible = 300 points

Course Project Milestone #2: Nursing Diagnosis and Plan of Care Form

Your Name: Date:

Your Instructor’s Name:

Directions: Refer to the Milestone 2: Guidelines found in Doc Sharing to complete the information below. This assignment is worth 300 points.

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 (15 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 (20 points)

Identify health education needs. Support your statements with facts from the Health History and information from your textbook.

2: Physical Examination Assessment

A. Vital signs (15 points)

B/P_________P_________R _________

Please document quality, characteristics, rate and depth:

B. Respiratory examination (30 points)

Ask relevant respiratory history and Review of Systems questions

History of Croup or Asthma? Y_________N_________

History of wheezing? Y_________N_________

Noisy breathing? Y_________N_________

Shortness of breath Y_________N_________

Chronic cough? Y_________N_________

Exposure to cigarette smoke of Environmental/Noxious fumes? Y_________N_________

If yes, explain_________

Most recent TB testing _________

Last Chest X Ray_________

Auscultate all lobes for lung sounds and document below.

RUL: __________

RM: L_________

RLL: _________

LUL: _________

LLL: _________

Document findings of the respiratory examination in Narrative Nursing Progress Notes (type below):

C. Cardiac examination (30 points)

Ask relevant cardiac and peripheral vascular history and review of systems questions

Any congenital heart problems?

Any history of murmur?

Any limitation of activity?

Any dyspnea on exertion?

Any history of palpitations?

Any history of high blood pressure?

Any coldness to extremities noted?

Assess general appearance including skin color and presence of visible pulsations

Inspect neck for visible carotid pulses and jugular venous distention

Inspect legs for edema and note if present:

1+ _________

2+ _________

3+ _________

Palpate all pulses, comparing left to right

Brachial: L _________R_________

Radial: L _________R _________

Femoral: L _________R _________

Popliteal: L _________R _________

Posterior tibial: L _________R _________

Dorsal pedia: L _________R _________

Test capillary refill, comparing left to right L _________R _________

Document findings of the cardiac examination in Narrative Nursing Progress Notes (type below):

D. Abdominal examination (30 points)

Ask relevant abdominal history and Review of Systems questions, including reproductive health history questions

Any abdominal pain?

Any nausea/vomiting?

Any history of ulcer?

Frequency of bowel movements, stool color and characteristics?

Any history of diarrhea?

History of constipation or stool holding?

Anal itching?

History of pinworms?

Any history of use of laxatives?

Rectal Bleeding

Inspect abdomen to assess contour and check for visible pulsations and peristalsis

Auscultate abdominal quadrants for bowel sounds

RUQ _________

RLQ _________

LUQ _________

LLQ _________

Document findings of the abdominal examination in Narrative Nursing Progress Notes (type below):

3: Nursing Plan of Care

Next, plan your care based on your analysis of your assessment data:

A. NANDA Nursing Diagnosis (15 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 (15 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.

Get a 30 % discount on an order above $ 50
Use the following coupon code:
COCONUT
Order your essay today and save 30% with the discount code: COCONUTOrder Now
Positive SSL