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milestone_2_guidelines.docx
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.
Directions
1. 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.
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 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 |
|
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 wellness diagnosis. 27-30 points |
Diagnosis not written in NANDA terms or does not reflect an illness, risk for illness or a wellness diagnosis. 25-26 points |
Diagnosis not written in NANDA terms and does not reflect an illness, risk for illness or wellness diagnosis. 22-24 |
Diagnosis is not documented 0-21 |
|
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 |
|
Milestone #2: Nursing Diagnosis and Care Plan Guidelines Rev. 8-6-13 jm |
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