Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation.7
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June 11, 2021Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation.7
Explore the professional responsibilities involved in conducting a comprehensive health assessment and providing appropriate documentation.7
Course Project Milestone 2
Course Project Milestone #2: Nursing Diagnosis and Care Plan Form
Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines for clarity of writing, which means the use of proper grammar, spelling and medical language.
Type your answers on this form. Click “Save as” and 1: Analyze Assessment Data:
Based on the health history information, identify the following:
Areas for focused assessment
Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.
Client’s strengths
Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.
Areas of concern
Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the textbook.
Health teaching topics
Identify health education needs. Support your statements with facts from the Health History and information from your textbook.
2: Nursing Care Plan
Next, plan your care based on your analysis of your assessment data:
Diagnosis
Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.
Plan Write one goal and one measurable expected outcome related to your nursing diagnosis. Explain why this goal and outcome is a priority. Include cultural considerations for this client.
Intervention
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
You will not carry out your care plan so you cannot evaluate the effectiveness of your nursing interventions. Instead, comment on what you would look for in order to evaluate your effectiveness.
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)
DIRECTIONS: 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.
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