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Nursing Diagnosis and Care Plan Assignment

Guidelines for Course Project Milestone 2:

Nursing Diagnosis and Care Plan Assignment

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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

CategoryPoints%Description
ANALYZE THE DATA
Areas for focused assessment3012Provide 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 strengths3012Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.
Areas of concern3012Expand 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 topics3012What health education needs have you identified? Support your statements with facts from the Health History and information from your textbook.
NURSING CARE PLAN
Diagnosis3012Write one nursing diagnosis that reflects a priority need for this person. Types of diagnoses include an illness, risk for illness or a wellness diagnosis.
Plan3012Write 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.
Intervention3012Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed
Evaluation3012You 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 WRITING104Use proper grammar, spelling and medical language
Total250 pts100%A quality paper will meet or exceed all of the above requirements.

Grading Rubric

Assignment CriteriaAOutstanding or highest level of performanceBVery good or high level of performanceCCompetent or satisfactory level of performanceFPoor or failing or unsatisfactory level of performance
Analyze the Data
Areas for focused assessment30 pointsIdentifies all strengths and weaknesses27-30 pointsOverlooks no more than 1 strength and/or 1 weakness25-26 pointsOverlooks more than 1 strength and 1 weakness22-24 pointsOverlooks more than 2 strengths and 2 weakness areas; item not included0-21
Client’s strengths30 pointsUses textbook (cites source) to validate all traits identified as strengths27-30 pointsUses textbook (cites source) to validate all but 1 trait identified as a strength25-26 pointsUses source to validate strengths, but not the textbook22-24Does not validate identified strengths0-21
Areas of concern30 pointsUses textbook (cites source) to validate all traits identified as concerns27-30 pointsUses textbook (cites source) to validate all but 1 trait identified as a concern25-26 pointsUses source to validate concerns, but not the textbook22-24Does not validate identified concerns0-21
Health teaching topics30 pointsIdentifies all areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)27-30 pointsIdentifies all but 1-2 knowledge deficits contained in Health History; validates findings using textbook (cites source)25-26 pointsFails to identify 3 areas of knowledge deficit contained in Health History; validates findings using textbook (cites source)22-24Does not validate findings with textbook0-21
Nursing Care Plan
Diagnosis30 pointsDiagnosis properly written in NANDA terms and reflects an illness, risk for illness or a wellness diagnosis.27-30 pointsDiagnosis not written in NANDA terms or does not reflect an illness, risk for illness or a wellness diagnosis.25-26 pointsDiagnosis not written in NANDA terms and does not reflectan illness, risk for illness or wellness diagnosis.22-24Diagnosis is not documented0-21
Plan30 pointsGoal realistic; outcome measurable and timed. Cultural considerations are identified and addressed.27-30 pointsGoal realistic but outcome not measurable or timed. Cultural considerations are mostly addressed25-26 pointsGoal somewhat realistic; outcome not measurable or timed. Cultural considerations are barely addressed.22-24Goal is not documented; cultural considerations are not adequately addressed0-21
Intervention30 pointsInterventions will aid in achievement of outcome; sound, rationale provided27-30 pointsInterventions will aid in achievement of outcome; rationale provided but not necessarily sound25-26 pointsInterventions incomplete and rationale provided but not necessarily sound22-24Interventions will not support outcome achievement; no rationale provided0-21
Evaluation30 pointsCriteria listed to thoroughly evaluate effectiveness of health education27-30 pointsCriteria listed mostly evaluates effectiveness of health education25-26 pointsCriteria listed partially evaluates effectiveness of health education22-24No evaluation criteria listed0-21
CLARITY OF WRITING10 pointsNo grammar, spelling, or syntax errors. Writes logically in complete sentences.10 pointsNo more than 2 errors of any type8-9 points2-3 errors of any type6-7 points3 or more errors of any type0-5 points
Total Points Possible = 250 pointsCourse Project Milestone #2: Nursing Diagnosis and Care Plan FormYour 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 PlanNext, 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 onemeasurable 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.

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