Paper, Order, or Assignment Requirements
Course Project Milestone #2: Nursing Diagnosis and Care Plan Form
Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines 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 1: Analyze Assessment Data:
Based on the health history information, identify the following:
Areas for focused assessment
Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.
Client’s strengths
Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.
Areas of concern
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.
Health teaching topics
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:
Diagnosis
Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.
Plan 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.
Intervention
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
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.
Guidelines for Course Project Milestone 2:
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)
DIRECTIONS: 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.
ANALYZE THE DATA
Areas for focused assessment 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 Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.
Areas of concern 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 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 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 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 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 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 Use proper grammar, spelling and medical language
.
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
Diagnosis properly written in NANDA terms and 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. Diagnosis not written in NANDA terms and does not reflect an illness, risk for illness or wellness diagnosis.
Diagnosis is not documented
**Plan
Goal realistic; outcome measurable and timed. Cultural considerations are identified and addressed.
Goal realistic but outcome not measurable or timed. Cultural considerations are mostly addressed
Goal somewhat realistic; outcome not measurable or timed. Cultural considerations are barely addressed.
Goal is not documented; cultural considerations are not adequately addressed
**Intervention
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
**CLARITY OF WRITING
No grammar, spelling, or syntax errors. Writes logically in complete sentences.
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