Chamberlain College of Nursing NR305 Health Assessment Course Project Milestone #2: Nursing Diagnosis and Care Plan Form Your 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 Plan Next, plan your care based on your analysis of your assessment data: Milestone #2: Nursing Diagnosis and Care Plan Form 8-6-13 jm 1 Chamberlain College of Nursing NR305 Health Assessment 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 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. Milestone #2: Nursing Diagnosis and Care Plan Form 8-6-13 jm 2 Chamberlain College of Nursing NR 305 Health Assessment 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) 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 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 Milestone #2: Nursing Diagnosis and Care Plan Guidelines Rev. 8-6-13 jm 1 Chamberlain College of Nursing NR 305 Health Assessment 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. Types of diagnoses include an illness, risk for illness or a wellness diagnosis. 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 prehypertensive 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 Overlooks more Overlooks more Analyze the Data Areas for Identifies all Overlooks no more Milestone #2: Nursing Diagnosis and Care Plan Guidelines Rev. 8-6-13 jm 2 Chamberlain College of Nursing Assignment Criteria A Outstanding or highest level of performance NR 305 Health Assessment B Very good or high level of performance C Competent or satisfactory level of performance F Poor or failing or unsatisfactory level of performance than 2 strengths and 2 weakness areas; item not included 0-21 focused assessment 30 points strengths and weaknesses 27-30 points than 1 strength and/or 1 weakness 25-26 points than 1 strength and 1 weakness 22-24 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 Does not validate validate strengths, identified strengths but not the textbook 0-21 22-24 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 Does not validate validate concerns, identified concerns but not the textbook 0-21 22-24 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 Diagnosis not written in NANDA terms and does not reflect an illness, Diagnosis is not documented 0-21 Nursing Care Plan Diagnosis 30 points Diagnosis properly written in NANDA terms and reflects an illness, risk for Diagnosis not written in NANDA terms or does not reflect an illness, illness or a wellness risk for illness or a risk for illness or diagnosis. wellness diagnosis. wellness diagnosis. 27-30 points 25-26 points 22-24 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 Interventions incomplete and rationale provided but not necessarily sound Interventions will not support outcome achievement; no rationale provided Milestone #2: Nursing Diagnosis and Care Plan Guidelines Rev. 8-6-13 jm 3 Chamberlain College of Nursing Assignment Criteria A Outstanding or highest level of performance B Very good or high level of performance NR 305 Health Assessment C Competent or satisfactory level of performance F Poor or failing or unsatisfactory level of performance sound 25-26 points 22-24 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 Milestone #2: Nursing Diagnosis and Care Plan Guidelines Rev. 8-6-13 jm 4 Chamberlain College of Nursing NR305 Health Assessment Course Project Milestone 1: Health History Form Your Name: Date: Your Instructor’s Name: Directions: Refer to the Milestone 1: Health History guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 175 points, with 5 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_Milestone1_Form_Smith” When you are finished, submit the form to the Milestone #1 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. Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” BIOGRAPHICAL DATA (10 pts) Date: Initials: Age: Date of birth: Birthplace: Gender: Marital status: Race: Religion: Occupation: Health insurance: Source of information: Reliability of source of information: PRESENT HEALTH HISTORY/ILLNESS (15 pts) Reason for seeking care: Health patterns: Health goals: HEALTH BELIEFS AND PRACTICES (15 pts) Beliefs and practices: Factors influencing healthcare decisions: Related traits, habits or acts: Milestone 1: Health History Form Rev. 8-6-13 jm 1 Chamberlain College of Nursing NR305 Health Assessment MEDICATIONS (15 pts) Prescription medications: Over-the-counter medications: Herbals: PAST HISTORY (15 pts) Childhood diseases: Immunizations: Allergies: Blood transfusions: Major illnesses: Injuries: Hospitalizations: Labor and deliveries: Surgeries: Use of alcohol: Use of tobacco: Use of illicit drugs: EMOTIONAL HISTORY (15 pts) Mental, emotional or psychiatric problems: FAMILY HISTORY (15 pts) Father: Mother: Siblings: Grandparents: PSYCHOSOCIAL/ OCCUPATIONAL HISTORY (15 pts) Occupational history: Educational level: Financial background: ROLES AND RELATIONSHIPS (15 pts) Significant others: Support systems: ETHNICITY AND CULTURE (10 pts) Ethnicity and culture: Physical and social characteristics that influence healthcare decisions: SPIRITUALITY (5 pts) Religious and spiritual needs: SELF-CONCEPT (5 pts) View of self-worth: Milestone 1: Health History Form Rev. 8-6-13 jm 2 Chamberlain College of Nursing NR305 Health Assessment Future plans: REVIEW OF SYSTEMS (20 pts) Skin, hair, nails: Head, neck, related lymphatics: Eyes: Ears, nose, mouth, and throat: Respiratory: Breasts and axillae: Cardiovascular: Peripheral vascular: Abdomen: Urinary: Reproductive: Musculoskeletal: Neurologic: Milestone 1: Health History Form Rev. 8-6-13 jm 3 Chamberlain College of Nursing NR 305 Health Assessment Guidelines for Course Project Milestone 1: Health History PURPOSE The student will obtain a health history on a willing, non-related, adult participant in order to generate written documentation that is clear and accurate. 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 175 points. DUE DATE The Course Project Milestone 1: Health History assignment is to be submitted to the Dropbox by Sunday, 11:59 p.m. MT at the end of this Week 4. The guidelines and grading rubric may be found in Doc Sharing. Post questions to the Q&A Forum. Contact your instructor if you need additional assistance. DISCLAIMER The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.” DIRECTIONS 1. Find an adult who is not related to you who is willing to let you take a health history. 2. Download the NR305_Milestone1_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 be clear in your communication by using correct medical terminology, grammar and spelling. 3. Review the examples in Chapter 10 of your textbook to gain insight into how to document the health history. Avoid words like frequently, improved, increased, decreased, good, poor, normal, or WNL as they may have different meanings for different people. Instead, document the specific data that led you to these conclusions, e.g., 3x/day instead of “frequently,” or consuming 4 servings of vegetables/day instead of “increased” vegetable servings. 4. Save the file by clicking “Save as” and adding your last name to the file name, e.g., “NR305_Milestone1_Form_Smith” Milestone #1 Health History.docx Rev. 8-6-13 jm 1 Chamberlain College of Nursing NR 305 Health Assessment 5. Submit the completed form to the Dropbox by Sunday, 11:59 p.m. MT at the end of Week 4. Please post questions in the weekly Q & A Forums so the entire class may view the answers. GRADING CRITERIA Category Points % Description Biographical Data 10 6 Date of health history, client’s initials, age, date of birth, birthplace, gender, marital status, race, religion, occupation, health insurance information, source of information, and the reliability of the source. Do NOT include identifying information such as phone numbers, address, etc. Present Health History/ Illness 15 9 Reasons for seeking care, health patterns, and health goals. Health Beliefs and Practices 15 9 Health beliefs and practices including factors that influence their healthcare decisions, related traits, habits or acts that affect a client’s health. Medications 15 9 Use of prescription medications, over-the-counter medications and/or any herbals. Include name, dose, purpose, duration, frequency and desired or undesired effects of each of the medications. Past History 15 9 Childhood diseases, immunizations, allergies, blood transfusions, major illnesses, injuries, hospitalizations, labor and deliveries, surgeries, and use of alcohol, tobacco and illicit drugs. Emotional History 15 9 Includes information about any mental, emotional, or psychiatric health problems. Family History 15 9 Review of health history of the father, mother, sibling(s) and grandparents to determine if any genetic or familial patterns of health or illness might affect current health status. Psychosocial/ Occupational History 15 9 Includes information about occupational history, educational level, and financial background. Roles and Relationships 15 9 Information about the client’s roles and relationships; including identifying a significant other and support systems (friends, neighbors, club members, clergy, church members and members of the healthcare team) Ethnicity and Culture 10 6 Client’s ethnicity and culture, and physical and social characteristics that influence healthcare decisions. Spirituality 5 3 Client’s religious and spiritual needs. (Spirituality refers to the individual’s sense of self in relation to others and a higher being.) Milestone #1 Health History.docx Rev. 8-6-13 jm 2 Chamberlain College of Nursing NR 305 Health Assessment Self-Concept 5 3 Includes information on how they view their self-worth and plans for the future. Review of Systems 20 12 Focus is to uncover current and past information about each body system and its organs. Ask about the system function and any abnormal signs or symptoms, paying attention to gathering information about the functional patterns of each system. Clarity of writing 5 3 Content is organized logically and clearly understandable. Documentation is clear and accurate. Words like frequently, improved, increased and decreased not used, instead provide specific examples. Total 175 pts 100% A quality paper will meet or exceed all of the above requirements. GRADING RUBRIC Assignment Criteria Exceeds Minimum Requirements Meets Minimum Requirements Partially Meets or Does Not Meet Minimum Requirements Biographical Data 10 points All required criteria included. No errors. 10 points No more than one required elements missing 8 points More than two required elements missing. 0-7 points Present Health History/Illness 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Health Beliefs and Practices 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Medications 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Past History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Emotional History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Milestone #1 Health History.docx Rev. 8-6-13 jm 3 Chamberlain College of Nursing NR 305 Health Assessment Assignment Criteria Exceeds Minimum Requirements Meets Minimum Requirements Partially Meets or Does Not Meet Minimum Requirements Family History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Psychosocial/ Occupational History 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Roles and Relationships 15 points All required criteria included. No errors. 12-15 points No more than three required elements missing 5-11 points More than three required elements missing. 0-4 points Ethnicity and Culture 10 points All required criteria included. No errors. 10 points No more than one required elements missing 8 points More than two required elements missing. 0-7 points Spirituality 5 points All required criteria included. No errors. 5 points No more than one required elements missing 4 points More than two required elements missing. 0-3 points Self-Concept 5 points All required criteria included. No errors. 5 points No more than one required elements missing 4 points More than two required elements missing. 0-3 points Review of Systems 20 points All required criteria included. No errors. 16-20 points No more than three required elements missing did not include information about functional patterns of each system. 10-15 points More than three required elements missing. Total body systems and/or functional patterns missing. 0-9 points Clarity of writing 5 points Organized logically and written clearly with good structure 4-5 points Lacks some organization & clarity. Uses words such as frequently, increased, decreased. 2-3 points Lacks logical organization; difficult to read. Uses words such as frequently, increased, decreased. 0-1 points Total Points Possible = 175 points Milestone #1 Health History.docx Rev. 8-6-13 jm 4
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