Nursing process assignment

Appendix A

Instructions and Rubric for Nursing Process Assignment: (10%)

Using the nursing process as a framework, please identify one topic of study and create a case scenario and a nursing plan of care using evidence-based practice for your interventions for the topic identified. 

  1. APA reference and title page.  All journal references must be within five years (2018-present).  Must use two journal articles.
  2. Assessment- use both subjective and objective data to form a data base.  Focused exam appropriate to problem identified.  Example: altered level of consciousness à Subjective: “I fell and hit my head yesterday” and objective: loss of consciousness (LOC), vital signs (VS), examination of but not limited to head, heart, lungs, abdomen, and any laboratory results that may be appropriate, etc.
  3. Nursing Diagnosis- use three (3) North American Nursing Diagnosis Association (NANDA), relate to etiology, as manifested by ________________.  Prioritize them from most important to least important.  They may be actual and potential.

Actual

(NANDA statement R/T etiology As Evidenced By (AEB)______signs & symptoms___.)

Potential (Risk for)

(NANDA statement R/T etiology.

  1. Planning- Identify one (1) long term goal, be specific, measurable, and with time frames identified.  Identify three (3) Short term goals be specific, measurable, and with realistic time frames.   
  2. Interventions- identify at least three (3) nursing interventions appropriate for each nursing diagnosis identified. Include a teaching Intervention
  3. Evaluation- identified how you would evaluate the plan of care and whether the goals/outcomes were partially met, met, or ongoing

Grading Rubric

CriteriaPointsGrade/Comments
Template Use: (see Care Plan Template below)+1 
Assessment Data: Subjective & Objective Data (listed & identified)+2 
Nursing Diagnosis/ with Pathophysiology: list 3, prioritize, correct NANDA statement for actual or potential (risk for)+2 
Plan: LT & ST goals specific, realistic, time frames included+2 
Interventions: at least 3 Include a teaching intervention+1.5 
Evaluation: goal met, partially met, not met+1.5 

Nursing Process Assignment Topics

Using this information and what you have learned about the disease state please develop a nursing care plan after summarizing what you have learned regarding the disease process and recording a complete assessment on the patient.

Choose one topic below:

1.A 74-year-old Caucasian female patient arrives on your nursing unit.  The patient has a known history of congestive heart failure (CHF), atrial fibrillation (A Fib), and severe osteoarthritis.  She lives at home alone and is reported to have fallen several times in the past two months.  Health history is significant for dementia as reported by her family and there is suspicion for depression.  Surgical history reveals bilateral knee replacements within the past six (6) years. Patient wears both upper and lower dentures.  Her ER notes states that she has increased shortness of breath (SOB) and swelling in her feet and legs bilaterally to mid-calf.  Due to her increased SOB she has been spending a great deal of time in bed or sitting in a chair for the past two weeks. Her medications are: enalapril (Vasotec), metoprolol succinate (Toprol XL), enoxaparin (Lovenox), and celecoxib (Celebrex).

2.A 53- year- old AA female patient arrives on your nursing unit.  She is having left lower quadrant pain, loose stool, nausea and is admitted with a diagnosis of diverticulitis.  The patient has had 4-5 bouts of this within the last 12 months.  Her husband is deceased, and she reveals that she and her 2 teenage children have been living on her income alone.  She is very thin, anxious, and has been a smoker for over twenty (20) years smoking 1 pack of cigarettes a day.  Her health history reveals moderate hypertension, shortness of breath (SOB) at times, and osteoporosis.  She was prescribed medications: hydrochlorthiazide (HCTZ), Albuterol inhaler, and alendronate (Fosamax), but it is unclear if she is taking them consistently and as prescribed.

3.An 82- year -old Asian male patient is admitted to your nursing unit.  He has a known history of chronic obstructive pulmonary disease (COPD) and came to the ER for chest pain.  His health history reveals hypertension, hyperlipidemia, and a previous admission for pneumonia.  The patient is accompanied by his wife who is heard of hearing.  When he is questioned about children in the area, he states “they’re busy with their own lives don’t call them.”  Surgical history is significant for a stent placement in a major artery in his heart last year.  Patient states “I limp because of an ankle injury I got during the Korean War.”  He uses a cane when he ambulates.  Patient appears unshaven, restless, and his clothes are dirty.  His medications are: budesonide (Pulmicort), ipratropium (Atrovent HFA), metoprolol succinate (Toprol XL), and rosuvastatin (Crestor).

CARE PLAN

STUDENT NAME/DATE:

PATIENT INITALS:/ (Scenario 1, 2, or 3)      

AGE:  

GENDER:

ETHNICITY:

RELIGION:

MEDICAL DIAGNOSES with Pathophysiology:

DEVELOPMENTAL STAGE (according to Erickson):

ASSESSMENT DATA (Subjective & Objective, list and identify):

MEDICATIONS:

MEDICATIONCLASSIFICATIONDOSAGEMAJOR SIDE EFFECTSCONTRA- INDICATIONSNURSING  IMPLICATIONS
      
      
      
      
      

NURSING DIAGNOSIS #1 (MUST PRIORITIZE USING NANDA AND MASLOW)

Diagnosis:

Long Term Goal:

Plan:

Short Term GoalsInterventionsScientific RationaleEvaluation
1.1.          1.      1.          
2.2.2.2.
333.3.
   4.        4.    4.    
 5.5.5.

NURSING DIAGNOSIS #2 (MUST PRIORITIZE USING NANDA AND MASLOW)

Diagnosis:

Long Term Goal:

Plan:

Short Term GoalsInterventionsScientific RationaleEvaluation
1.1.          1.      1.       
2.2.2.2. 
3.3.3.3. 
3.  4.        4.      4       
 5.5.5. 

NURSING DIAGNOSIS #3 (MUST PRIORITIZE USING NANDA AND MASLOW)

Diagnosis:

Long Term Goal:

Plan:

Short Term goalsInterventionsScientific RationaleEvaluation           
1.1.         2.      1.     2.      1.     2.
2.33.3.
3.4.  4        4.        
 5.5.5.

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