Identify teaching/learning needs from the health history of an individual.
Identify teaching/learning needs from the health history of an individual.
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
Category Points% Description
ANALYZE
THE DATA
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DeVry NR305 – Nursing Diagnosis and Care Plan Assignment
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Dated: 7th Dec’15 07:37 PM
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10/9/2017 DeVry NR305 – Nursing Diagnosis and Care Plan Assignment – SKU 105382
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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. Illness, risk for illness and health promotion diagnoses will be
accepted.
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 pre-hypertensive
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.
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
30 points
Identifies all strengths and weaknesses
27-30 points
Overlooks no more than 1 strength and/or 1
weakness
25-26 points
Overlooks more than 1 strength and 1
weakness
22-24 points
Overlooks more than 2
strengths and 2 weakness
areas; item not included
0-21
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
Does not validate identified
strengths
0-21
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
Does not validate identified
concerns
0-21
Health
teaching
topics
30 points
Identifies all areas of knowledge deficit
contained in Health History; validates
findings using textbook (cites source)
27-30 points
Identifies all but 1-2 knowledge deficits
contained in Health History; validates
findings using textbook (cites source)
25-26 points
Fails to identify 3 areas of knowledge
deficit contained in Health History;
validates findings using textbook (cites
source)
22-24
Does not validate findings
with textbook
0-21
Nursing
Care Plan
Diagnosis
30 points
Diagnosis properly written in NANDA
terms and reflects an illness, risk for
illness or a health promotion diagnosis.
27-30 points
Diagnosis not written in NANDA terms or
does not reflect an illness, risk for illness or a
health promotion diagnosis.25-26 points
Diagnosis not written in NANDA terms
and does not reflectan illness, risk for
illness or a health promotion diagnosis.
22-24
Diagnosis is not
documented
0-21
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10/9/2017 DeVry NR305 – Nursing Diagnosis and Care Plan Assignment – SKU 105382
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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
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
Goal is not documented;
cultural considerations are
not adequately addressed
0-21
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
Interventions will not
support outcome
achievement; no rationale
provided
0-21
Evaluation
30 points
Criteria listed to thoroughly evaluate
effectiveness of health education
27-30 points
Criteria listed mostly evaluates effectiveness
of health education
25-26 points
Criteria listed partially evaluates
effectiveness of health education
22-24
No evaluation criteria listed
0-21
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
6-7 points
3 or more errors of any type
0-5 points
Total Points
Possible =
250 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 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 Plan of Care
Next, 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 health promotion 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 (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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