Nursing Diagnosis and Care Plan Form
Directions: Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelines and grading rubric found in Doc Sharing to complete the information below. This assignment is worth 250 points, with 10 points awarded 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 save the file with the assignment name and your last name, e.g., “NR305_Milestone2_Form_Smith” When you are finished, submit the form to the Milestone 2 Dropbox by the deadline indicated in your guidelines. Post questions in the Q&A Forum or contact your instructor if you have questions about this assignment.
1: Analyze Assessment Data:
Based on the health history information, identify the following:
A. Areas for focused assessment (30 points)
Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.
B. Client’s strengths (30 points)
Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.
C. Areas of concern (30 points)
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.
D. Health teaching topics (30 points)
Identify health education needs. Support your statements with facts from the Health History and information from your textbook.
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2: Nursing Care Plan
Next, plan your care based on your analysis of your assessment data:
A. Diagnosis (30 points)
Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.
B. Plan (30 points)
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.
C. Intervention (30 points)
Write as many nursing orders or nursing interventions that you need in order to achieve the outcome. Provide the rationale for each intervention listed.
D. Evaluation (30 points)
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.
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