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Purpose

The purpose of this assignment is to promote clinical judgment in connection with the nursing process. The student will be able to demonstrate the application of connecting concepts, prioritizing nursing care and intentional decision making.

Course outcomes

CO 1: Demonstrate the nursing process while providing basic care to individuals and families reflecting different stages of the life span in extended care, acute care, and community-based settings. (PO 1)

CO3: Demonstrate communication skills necessary for interaction with other health team members and for providing basic nursing care to individuals and families. (PO 3)

CO4: Incorporate critical thinking skills into clinical nursing practice. (PO 4)

AACN Essentials

Domain 1: Knowledge for Nursing Practice

Domain 2: Patient-Centered Care

Domain 5: Quality and Safety

Due date

Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Total points possible

100 points

Assignment Guidelines

Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions. 

· Fill out the provided template based on the complete physical assessment you performed while providing care in the clinical or virtual setting.

· Use the provided NR226 RUA Template

Introduction of Disease

(10 points/10%)

|_| Age and reason for hospitalization (medical diagnosis).

|_| Nursing concept connected to reason for hospitalization.

Safety-Communication-Infection Control (16 points/16%)

|_| Provide specific communication elements used when providing care for this client.

|_| Provide specific safety concerns identified when providing care for this client.

|_| Provide infection control practices followed when providing care for this client.

Assessing: Recognize/Identify Cues (15 points/15%)

|_| Provide four (4) cues identified during your comprehensive head to toe assessment (abnormal assessment findings, labs, diagnostics, etc.)

|_| Cue 1

|_| Cue 2

|_| Cue 3

|_| Cue 4

|_| Provide (1) cue identified during your comprehensive assessment that is a psychosocial need.

|_| Psychosocial Cue

Nursing Diagnosis: Analyze Cues/ Prioritize Hypothesis (20 points/ 20%)

|_| From your previous list, select 3 cues as areas of concern for this client.

|_| Prioritize your cues/ areas of concern.

|_| Cue/ area of concern that is high priority

|_| Cue/ area of concern that is medium priority

|_| Cue/ area of concern that focuses on psychosocial needs.

|_| Provide a short summary rationale explaining why these areas of concern were chosen and their connection to the client.

Planning: Generating Solutions

and

Implementation: Taking Action

(30 points/30%)

|_| Develop one (1) S.M.A.R.T. goal for each area of concern.

|_| Provide rationale for the goal.

|_| Provide one (1) client specific intervention to help obtain the goal for each area of concern.

|_| Cue/area of concern that is high priority.

|_| S.M.A.R.T. goal

|_| Rationale for goal

|_| Client specific intervention

|_| Cue/ area of concern that is medium priority.

|_| S.M.A.R.T. goal

|_| Rationale for goal

|_| Client specific intervention

|_| Cue/ area of concern that is psychosocial.

|_| S.M.A.R.T. goal

|_| Rationale for goal

|_| Client specific intervention

Evaluation: Evaluating Outcomes (5 points/5%)

|_| Determine if goals were met or not.

|_| Provide evidence that supports that determination.

|_| Describe what changes, if any, are needed to achieve goals in the future.

APA Citations and Writing (4 points/4%)

|_| Provide at least two (2) scholarly, primary sources from the last 5 years, excluding the textbook.

|_| Use current APA format and is free of errors. 

|_| Grammar and mechanics are free of errors. 

|_| Citations in the text and reference page

Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review module.

For writing assistance, please visit the Writing Center.

Assignment Section and

Required Criteria

(Points possible/% of total points available)

Highest Level of Performance

High Level of Performance

Satisfactory Level of Performance

Unsatisfactory Level of Performance

Section not present in paper

Introduction of Disease

(10 points/10%)

10 points

8 points

6 points

4 points

0 points

Required criteria

1. Provides age and reason for hospitalization (medical diagnosis).

2. Provides nursing concept connected to reason for hospitalization.

3. Provides brief review of underlying pathophysiology

a. Describes what functional changes can happen as part of the disorder.

b. Describes what complications can happen as part of the disorder.

c. Includes scholarly citation(s)/ reference to support information.

Includes all 5 requirements per section (1,2,3a,3b,3c).

Includes 4 requirements per section.

Includes 3 requirements per section.

Includes 2 requirements per section.

Includes 1 or fewer requirements per section.

Safety-Communication-Infection Control

(16 points/16%)

16 points

10 points

0 points

Required criteria

1. Provides specific communication elements used when providing care for this client.

2. Provide specific safety concerns identified when providing care for this client.

3. Provide infection control practices followed when providing care for this client.

Includes all 3 requirements per section (1,2,3).

Includes 2 requirements per section.

Includes 1 or fewer requirements per section.

Assessing: Recognize/Identify Cues

(15 points/15%)

15 points

12 points

9 points

6 points

0 points

Required criteria

1. Provides four (4) cues identified during comprehensive head to toe assessment (abnormal assessment findings, labs, diagnostics).

a. Clearly describes cue #1.

b. Clearly describes cue #2.

c. Clearly describes cue #3.

d. Clearly describes cue #4.

2. Provides (1) cue identified during comprehensive assessment that is a psychosocial need.

a. Clearly describes psychosocial cue.

Includes all 5 requirements per section (1a,1b, 1c, 1d, 2a).

Includes 4 requirements per section.

Includes 3 requirements per section.

Includes 2 requirements per section.

Includes 1 or fewer requirements per section.

Nursing Diagnosis: Analyze Cues/ Prioritize Hypothesis

(20 points/ 20%)

20 points

15 points

10 points

0 points

Required criteria

1. Prioritizes cues/ areas of concern.

a. Cue/ area of concern that is high priority

b. Cue/ area of concern that is medium priority

c. Cue/ area of concern that focuses on psychosocial cue/area of concern.

2. Provides a short summary rationale explaining why these areas of concern were chosen and their connection to the client.

Includes all 4 requirements per section (1a, 1b, 1c, 2).

Includes 3 requirements per section.

Includes 2 requirements per section.

Includes 1 or fewer requirements per section.

Planning: Generating Solutions

and

Implementation: Taking Action

(30 points/30%)

30 points

23 points

13 points

0 points

Required criteria

1. Develops one (1) S.M.A.R.T. goal for the high priority area of concern. Provides a rationale for goal and provides 1 intervention.

a. S.M.A.R.T. goal for cue/ area of concern that is high priority.

b. Rationale for goal.

c. Intervention for goal.

2. Develops one (1) S.M.A.R.T. goal for the medium priority area of concern. Provides a rationale for goal and provides 1 intervention.

a. S.M.A.R.T. goal for cue/ area of concern that is high priority.

b. Rationale for goal.

c. Intervention for goal.

3. Develops one (1) S.M.A.R.T. goal for the high priority area of concern. Provides a rationale for goal and provides 1 intervention.

a. S.M.A.R.T. goal for cue/ area of concern that is high priority.

b. Rationale for goal.

c. Intervention for goal.

Includes all 9 requirements per section (1a, 1b, 1c, 2a, 2b, 2c, 3a, 3b, 3c).

Includes 7 requirements per section.

Includes 4 requirements per section.

Includes 1 or fewer requirements per section.

Evaluation: Evaluating Outcomes

(5 points/5%)

5 points

4 points

2 points

0 points

Required criteria

1. Determines if goals/outcomes were met.

2. Provides evidence that supports determination.

3. Describes what changes, if any, are needed to achieve goals in the future.

Includes all 3 requirements for section.

Includes 2 requirements for section.

Includes 1 requirement for section.

No requirements for this section presented.

APA Citations and Writing

(4 points/4%)

4 points

3 points

2 points

1 point

0 points

Required criteria

1. Provides at least two (2) scholarly, primary sources from the last 5 years, excluding the textbook.

Includes 4 requirements per section.

Includes 3 requirements per section.

Includes 2 requirements per section.

Includes 1 requirements per section.

No requirements for this section presented.

Total Points Possible = 100 points