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 abriefoverview 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) Writeonenursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility. B. Plan (30 points) Writeonegoal andonemeasurable 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 manynursing orders, ornursing interventionsthat you need in order to achieve the outcome.Provide the rationalefor 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. 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 bySunday, 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 oneNANDA-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 Writeone goalandonemeasurableexpectedoutcomerelated 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 anillness, risk for illness or a wellness diagnosis. (13-15 points) Diagnosis not written in NANDA terms or does not reflect anillness, 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)
