Nursing Question

Objectives:

1. 2. 4. 5. 6. Develop individualized client care plan using the nursing process

Prioritize client problems and/ or wellness opportunities.

3. Formulate nursing diagnoses.

Develop client-centered goals and nursing interventions.

Describe the scientific rationale for each nursing intervention.

Evaluate the clients responses to interventions carried out on the case study in relation to

treatment goals or how the nurse would effectively evaluate clients progress toward goals.

Assignment Guidelines:

1. You will choose a patient that you have cared for in the clinical environment. Use your patients

medical record to gather all the information needed to write a formal care plan plus a written section

describing your clients assessment findings (I.e. demographic information, past medical history,

history of current admission, physical assessment, and medications).

2. Refer to the Nursing Process Paper (NPP) Evaluation Criteria and Grading Rubric to develop the

assignment

3. Identify four (4) NANDA-approved nursing diagnostic statements using a worded three-part diagnostic

statement for the actual problems or two-part statement for at-risk problems. From these four-

nursing diagnoses, choose the two (2) most important nursing diagnoses. You will list all four NDs in

your paper and indicate the rational for choosing the two final nursing diagnoses.

4. Using the suggested care plan format show below:

a. List one short-term and one long-term goal for each nursing of the two chosen priority

nursing diagnosis.

b. List five (5) nursing interventions for each of the remaining Nursing Diagnosis to address the

short and long-term goals for each of the chosen nursing

i. Provide a scientific rationale for each intervention

c. Evaluate whether the patient met the goal or not. If unable to evaluate if the patient met the

goal or not, describe what patient actions or results would indicate that the goals were met. If

the goal are not met, what changes to the care plan might need to be implemented.

5. APA format.

6. Be sure to use your textbooks to assist you. All sources used in creating this paper must be listed on

the reference page, cited correctly within the body of the paper and should be less than 5 years old.Assessment

(20%)

Nursing Diagnosis

(20%)

Planning

(10%)

Novice 10 Points or less

Assessment of client needs is absent,

inaccurate, or includes incomplete objective

&/or subjective data

* Demographic, past medical history (PMH),

history of current admission, subjective &

objective data including laboratory, physical

assessment, diagnostic studies, &

medications as appropriate

*Breech of client confidentiality

10 Points or less

Lacks prioritization of problems/educational

or wellness opportunities

* Identifies 2 NANDA approved nursing

diagnostic statements.

* Identifies 1 high priority client problems

* Nursing diagnoses do not relate to client

problems

* Inaccurately written or insufficiently

developed nursing diagnoses

* Lack of rationale to support priority

diagnoses and/or no cited references

6 Points or less

* Goals are absent or not related to each

chosen nursing diagnosis

* Goals are not directly related to patient

problem or inappropriate for the patient

Novice Developing 11-16 Points

Assessment of client needs is incomplete or

inadequate objective &/or subjective data

*Demographic, past medical history (PMH),

history of current admission, subjective &

objective data including laboratory, physical

assessment, diagnostic studies, & medications

*Maintains confidentiality

11-16 Points

Identifies and prioritizes most problems/

educational or wellness opportunities.

Accurately:

* Identifies at least 3 NANDA approved nursing

diagnostic statements.

* Identifies 2 highest priority client problems

* Cites rationale for 2 priority diagnoses and

cites references

* Writes a 3-part statement for actual problems

or 2 part statement for risk for problems

7-8 Points

* Assigns 1 short-term and 1 long-term goal for

each nursing diagnosis

*Goals are identified, but are not specific,

measurable individualized, &/or patient

centered

*Goals are not clearly related to nursing

diagnosis or appear to be inappropriate for the

client care needs

Developing Proficient

17-20 Points

* Includes complete assessment of client needs.

*Assessment of client needs includes objective &

subjective data – such as demographic, past

medical history (PMH), history of current

admission, subjective & objective data including

laboratory, physical assessment findings,

diagnostic studies, & medications as appropriate

in addition to physical assessment data

* Maintains confidentiality

17-20 Points

Identifies and prioritizes problems/ educational

or wellness opportunities. Accurately:

* Identifies 4 NANDA approved nursing

diagnostic statements.

*Writes a 3-part statement for actual problems

or 2 part statement for risk for problems

* Identifies 2 of the highest priority NANDA

approved nursing diagnostic statements.

* Describes the reasoning behind the choosing

the 2 priority diagnoses in a logical and

professional manner with evidence and citations

to support this choice.

9-10 Points

* Assigns 1 short-term and 1 long-term goal for

each nursing diagnosis

*Goals are specific, measurable, individualized,

patient centered and relate to the nursing

diagnosis

*Goals are appropriate for the client and directly

related to client care needs

ProficientImplementation

(25%)

14 Points or less

* Identifies <5 nursing interventions

* Interventions lack detail and/or are not

appropriate to meet identified goals

* Interventions are not supported by

appropriate rationales &/or references

* Strategies are not individualized, specific

appropriate for identified goals

15-19 Points

* Identifies five (5) nursing interventions

* Interventions contain limited details

* Interventions do not clearly support identified

goals

* Interventions are supported by limited

rationales &/or references

*Strategies demonstrate limited

individualization &/or are not clearly

appropriate for the identified goals

20-25 Points

* Identifies five (5) nursing interventions

* Interventions are comprehensive, detailed, &

appropriate for identified goals

* Interventions include assessment, independent

intervention, dependent interventions and

education

* Interventions are supported by appropriate

rationales & references

* Strategies are specific, individualized, and

appropriate for identified goals

Evaluation

(10%)

6 Points or less

* Assessment of clients responses to

interventions and progress toward goals are

not specific, measurable, &/or realistic, or do

not include observable behaviors

*Lacks identification of goals met or not.

* If goals not met, does not include why not

met or identify any changes needed to plan of

care

7-8 Points

* Assessment of clients responses to

interventions and progress toward goals are not

fully specific or realistic, &/or include only

limited discussion of observable behavior

* Provides rationale for interventions not

implemented

* Identifies goals met or not. If goals not met,

includes why not met but does not identify any

changes needed to care plan

9-10 Points

* Assessment of clients responses to

interventions and progress toward goals are

specific, realistic, & include observable

behaviors.

* Provides rationale for interventions not

implemented

* Identifies goals met or not. If not met, includes

why not met and identifies changes needed

Professional

Writing

(10%)

5 Points or less

* Writing includes numerous grammar &

spelling errors

* Lack of organization detracts from

readability

* Writing style is inappropriate for an

academic paper.

* Includes < 2 appropriate professional

references

* Most references are intended for the non-

professional audience

* APA format is not followed

* Paper is submitted late

* Citations are missing

* Evidence of plagiarism or use of AI is

indicated by Turnitin

6-10 Points

* Writing includes minimal grammar & spelling

errors.

* Lack of organization detracts from readability

in areas

* Writing style is inappropriate for an academic

paper in areas

-* Includes < 3 appropriate professional

references

* Some references are intended for the non-

professional audience

* APA format is followed inconsistently

* Paper is submitted on time

* Some in text citations are missing

11-15 Points

* Writing is clear, organized, and free from

grammar & spelling errors

* Writing style is appropriate for academic paper

* Includes at least 3 appropriate professional

references

* All references are intended for the professional

audience

* APA format is followed throughout

* Only 1 or less direct quote is used

* Appropriate in text citations throughout

Total Points

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