MD1 MODULE 6

Assessment

Three NANDA-I Approved

One Smart Goal for EACH

Two Nursing Interventions

and

Data Collection

Nursing Diagnosis

*Risk: Nursing diagnosis

Related to_____

*Actual: Nursing diagnosis

Related to____ as evidenced by

ONE SENTENCE

Nursing Diagnosis

*Specific and measurable with a timeline. Find from the nursing diagnosis book (under client or expected outcomes section) and individualize to your patient-ONE

SENTENCE

with Rationale for EACH

Nursing Diagnosis

*From nursing diagnosis book under interventions section.

Choose 3 and individualize to patient. Cite these interventions.

Disease Process: (short description of path of disorder- cite this):

Itching of the skin under the cast causes the patient to scratch himself with hunger

Nursing Diagnosis:

Moisture build-up under the cast is the diagnosis related to the patient scratching himself under the form, as evidenced by

Rubin, 2017.

SMART Goal:

I will reduce the moisture build-up in the patient cast by half by reducing the air that gets into the form and controlling what the patients

1. By the end of my shift, the patient will have reduced the moisture in the cast significantly by using a blow drier to reduce the water in the

(Rubin, 2017)

Common

Labwork/Diagnostics:

For the itchy skin, the

Nursing Diagnosis:

After the diagnostics, the itching on the skin is related to

do.

SMART Goal:

The patient should be

relaxed setting.

2. By the end of my shift, the itching and scratching that is being witnessed currently will also be reduced by ensuring that any movements made by the patient are monitored.

1. By the end of my shift, the

diagnostics that can be done on this is taking samples on the part of the skin that is itching and taking them to the lab to identify if any infections are seen on that part of the skin (Wachsmuth, 2018).

Assessment Data (consider subjective, objective, and health history):

The patient is restless and prefers to do most of the

the patient interacting with moisture on different occasions, either by using the washrooms or while taking a bath. This is as evidenced by Wachsmuth, 2018).

Nursing Diagnosis

Patients with old ages are most likely to demonstrate these

monitored every two hours to ensure that he is being helped to go to the washrooms and that the cast does not contact any moisture.

SMART Goal:

The patient needs to be monitored every two hours to

patient will not have made any movements by himself; he should be monitored every two hours to help him in mobility

2. The patient will not have had come into contact with any wet surface, and he will be using his crutches while making every movement

activities by himself. Also, the patient is reluctant to ask for help when it comes to asking for help in movement. Also, the patient needs more monitoring as the excess sitting in one position might lead to more complicated effects on the injury (Wachsmuth, 2018).

identified symptoms, and this is evidenced by (Wachsmuth

2018)

ensure that the patient does not carry out any activity by himself and ensure that his mobility and positioning while sitting are monitored and done to enhance his recovery.

1. The patient should be able to communicate his feelings when he needs to be helped by the nurse when he needs to be moved from one place to another

2. By the end of my shift, the patient should have reduced any form of itching and avoid sitting in one dependent position for long periods.

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Assessment / Data

Collection

(10 Pts)

Lacks essential factors of the disease process, standard labs, diagnostic tests, and subjective, objective, and health history data.

Failure to submit

Assessment/Data Collection will result in zero points for this criterion.

Briefly identifies the factors including the disease process, standard labs, diagnostic tests, and subjective, objective, and health history data.

Identifies the factors, including the disease process, standard labs, and diagnostic tests, and subjective, objective, and health history data.

Thoroughly identifies all factors, including the disease process, standard labs, diagnostic tests, and subjective, objective, and health history data with a deep understanding.

Points – 7

Points – 8

Points – 9

Points - 10

Nursing Diagnosis

Nursing diagnosis are insufficient and/or do not fit

Writes ONE NANDA-I

approved nursing diagnosis

Writes TWO

NANDA-I approved

Writes THREE

NANDA-I approved

(should fit the data)

(10 Pts)

the data.

Failure to submit Nursing Diagnosis will result in zero points for this criterion.

in the correct format (including related to/as evidenced by) with a strong connection to identified data.

nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data.

nursing diagnoses in the correct format

(including related to/as evidenced by) with a strong connection to identified data.

Points – 7

Points – 8

Points – 9

Points - 10

SMART Goal

(should reflect the diagnosis and follow guidelines)

(15 Pts)

The goals meet few

SMART goal guidelines

and/or are not related to the nursing diagnoses. Failure to submit SMART goals will result in zero points for this criterion.

Writes ONE goal for ONE nursing diagnosis and the goal meets all the SMART goal guidelines and are related to the nursing diagnosis.

Writes ONE goal for TWO nursing diagnoses and the goals meet all the

SMART goal

guidelines and are related to the nursing diagnoses.

Writes ONE goal for THREE nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Points – 11

Points – 12

Points – 13

Points – 15

Interventions and

Rationale

(20 Pts)

Lacks appropriate interventions and rationale to assist the client in resolving the issues leading to the problem.

Failure to submit

Interventions and Rationale will result in zero points for this criterion.

Writes 3 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes more than 2 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Points – 15

Points – 16

Points – 18

Points –20

APA Citation

(5 Pts)

APA in-text citations and references are missing.

Attempted to use APA intext citations and references.

APA in-text citations and references are used with few errors.

APA in-text citations and references are used correctly.

Points- 2

Points- 3

Points- 4

Points- 5

Spelling and

Grammar

(5 Pts)

Numerous spelling and grammar errors, which detract from the audience's ability to comprehend material.

Some spelling and grammar errors, which detract from the audience's ability to comprehend material.

Few spelling and grammar errors.

Minimal to no spelling and grammar errors.

Points- 2

Points- 3

Points- 4

Points- 5