1. Medical history- Describe the pathophysiology of the medical diagnoses of your assigned patient. Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis is the reason for being in the facility. If post-surgical, include surgery and reason for surgery. If your client is in a long-term care facility, why do they need 24-hour nursing care? The secondary diagnoses include a history of pre-existing medical diagnoses. You need to include 4 secondary diagnoses. For each diagnosis, provide at least a 5-sentence explanation of the pathophysiology of the condition/problem. This section should be at least 2 pages in length. MAKE SURE YOU CITE YOUR SOURCES.
5 points
2. Nursing Care Plan- Upload the table below into your paper. Include 4 nursing diagnoses, one short-term and one long-term goal PER NURSING DIAGNOSIS, and four interventions PER NURSING DIAGNOSIS (not per goal, unless you want to). One nursing intervention should be an assessment; two nursing interventions should be nursing actions; one nursing intervention should include client teaching. Then, in one paragraph, prioritize your nursing diagnoses per Maslow with an explanation and an expected evaluation. Make sure to include a teaching plan in your care plan. Reflect on the following in your paper: Which of your nursing diagnoses are priority using Maslow’s Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term expected outcomes met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift?
NURSING CARE PLAN- Utilize your assessment data and the NURSING PROCESS to create an individualized Care Plan for your patient, be specific to their needs. Make sure one of your NDx is directed towards patient teaching (deficient knowledge).
Nursing Diagnoses
Use your Assessment data to ID clinical problems
Expected Outcomes (S.M.A.R.T.)
Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation)
Nursing Interventions
What can you, the nurse, do to reach the goal and improve the problem? Include citations to support each nursing interventions.
#1
R.T.
A.E.B.
The patient will…
Short-term goal:
Long-term goal:
The nurse will…
1.
2.
3.
4.
#2
R.T.
A.E.B.
Short-term goal:
Long-term goal:
1.
2.
3.
4.
#3
R.T.
A.E.B.
Short-term goal:
Long-term goal:
1.
2.
3.
4.
#4
R.T.
A.E.B.
Short-term goal:
Long-term goal:
1.
2.
3.
4.
Rubric for Part 2 (Due Week 7): 25 Points
Topic
Points
Medical history- describe the Pathophysiology of the admitting diagnosis & 4 secondary medical diagnoses (at least 5 sentences per diagnosis- at least 1 page in length)
5
Complete table:
Identify 4 NANDA-I nursing diagnoses, one short term goal and one long term goal that are S.M.A.R.T. per diagnosis.
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