NUR2356 Module 04 Written Assignment – Nursing Diagnosis

Document Content and Description Below

Module 04 Written Assignment – Nursing Diagnosis Purpose of the Assignment 1. Assist students in clustering assessment data when developing a nursing diagnosis. 2. Develop students’ ability t... o write client based outcomes when planning care. Course Competencies • Explain components of multidimensional nursing care for clients with musculoskeletal disorders. Instructions Using the template below the instructions, write 3 nursing diagnoses in proper format based on the client case provided below. Write one SMART client-centered outcome for each diagnosis. Consider the client’s medical history and medications. Kacie Benson, a 19 year-old woman, is a client on your unit as a result of a skiing accident. She is unconscious and may or may not regain consciousness. She is on complete bedrest. She requires frequent repositioning to maintain correct body alignment and attention to her ROM. She responds to painful stimuli with slight non-purposeful withdrawal. No spontaneous movements are noted. The recent lower extremity ultrasound showed no evidence of venous thrombosis and she continues on low molecular weight heparin injections. Her fluid and electrolyte balance is being maintained by a tube feeding at 60 mL per hour continuously. She is incontinent of stool and has an indwelling Foley catheter. Her heels are reddened, but otherwise her skin is intact. Use at least two scholarly sources to support your nursing diagnoses. Be sure to cite your sources in-text and on a reference page using APA format. Check out the following links for information about writing SMART goals and to see examples: http://rasmussen.libanswers.com/faq/212524 You can find useful reference materials for this assignment in the School of Nursing guide: https://guides.rasmussen.edu/nursing/referenceebooks Have questions about APA? Visit the online APA guide: https://guides.rasmussen.edu/apa Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis Mobility: Bed Impaired Electrolyte Imbalance Risk for infection Related to loss of Related to loss of Related to loss of consciousness due to consciousness consciousness and skiing accident. Being maintained by a movement Requires frequent tube feeding at 60 mL/hr Frequent heparin repositioning to maintain injections correct body alignment Feeding tube Bowel Incontinence Stool incontinence and Requires indwelling catheter to urinate indwelling foley catheter. SMART Goal SMART Goal SMART Goal Patient will regain Patient will regularly Patient will be free of consciousness and will be achieve electrolyte hospital acquired able to move within six balance with help of infection throughout her months. nursing staff maintaining stay. tubing feed throughout her stay at the hospital. Module 04 Written Assignment – Nursing Diagnosis Rubric Total Assessment Points - 35 Levels of Achievement Criteria Emerging Competence Proficiency Mastery Nursing Hypothesis/Diagnosi s (should fit the data) (10 Pts) Nursing hypothesis/diagnosi s is insufficient and/or does not fit the data. Writes nursing hypothesis/diagnosi s in the correct format with little connection to identified data. Writes nursing hypothesis/diagnosi s in the correct format with an adequate connection to identified data. Writes nursing hypothesis/diagnosi s in the correct format with a strong connection to identified data. Points – 0-7 Points – 8 Points - 9 Points - 10 SMART Goal (should reflect the diagnosis and follow guidelines) (15 Pts) The goal meets few SMART goal guidelines and/or is not related to the nursing diagnosis. The goal meets some of the SMART goal guidelines and is related to the nursing diagnosis. The goal meets most of the SMART goal guidelines and is related to the nursing diagnosis. The goal meets all of the SMART goal guidelines and is related to the nursing diagnosis. Points – 0-11 Points - 12 Points - 13 Points – 14-15 Spelling and Grammar (5 Pts) Numerous spelling and grammar errors, which detract from the audience's ability to comprehend material. Some spelling and grammar errors, which detract from the audience's ability to comprehend material. Few spelling and grammar errors. Minimal to no spelling and grammar errors. Points: 0-2 Points: 3 Points: 4 Points:5 APA Citation (5 Pts) APA in-text citations and references are missing. Attempted to use APA in-text citations and references. APA in-text citations and references are used with few errors. APA in-text citations and references are used correctly. Points:0-2 Points:3 Points:4 Points:5 [Show More]

Last updated: 1 year ago

Preview 1 out of 4 pages