Nursing Process

Question One Module 04 Written Assignment Nursing Process – Case Study Please read the following case study and complete the questions below. Daniel is a 16 year old boy who is an identical twin. He and his brother Jeff are very close and do most things together. While Daniel excels at sports he believe his brother is much better at most everything. Daniel, his brother, and their two sisters live with their parents in the Midwest. Recently Daniel has been feeling more tired than usual. He thought it was because of his schedule and school work, which he is fairly good at. He gets mostly Bs, but his grades have been slipping of late. One day he fainted while getting ready for a game. His coach called his parents to let them know Daniel was taken to the Emergency Room. While there the doctor decided to admit Daniel to the hospital for observation. At the time he was running a slight fever, his breathing was shallow, and he was sweating. He was also very sleepy and his blood pressure was high. He did have some abnormal laboratory work, but his doctor was not too concerned at present. Daniel also stated that he felt achy. You are assigned to take care of Daniel today and when you walk into his room, his mother and brother Jeff are there. Daniel appears to be sleeping. In your written assignment, respond to the following questions applying the nursing process: Assessment: What type of objective and subjective data can you collect with what you know? How will you collect these data? What further evidence do you need? Analysis and Identification of the Problem: What do you believe Daniel’s problem(s) are? What might be the nursing diagnoses? Use the following for identification. Planning: Identify two goals and one nursing intervention for each, based on your nursing diagnoses. While you will not be able to implement or evaluate, how well do you think your nursing interventions might help with Daniel’s care. Rubric Subjective and Objective Data Problem and Nursing Diagnosis Unsatisfactory Needs Improvement Satisfactor Points: Points: Points: 0 (0.00%) 1 (10.00%) 2 (20.00% Does not correctly identify subjective or objective data. Correctly identifies and lists at least one type of subjective OR objective data Correctly id least one ty AND object Points: Points: Points: 0 (0.00%) 1 (10.00%) 2 (20.00% Does not identify client problem or NANDA approved nursing diagnosis. Correctly identifies client problem OR NANDA approved nursing diagnosis with all required parts. Nursing Process

Correctly id problem AN approved n with all requ Unsatisfactory Needs Improvement Satisfactor Two SMART Goals For Nursing Diagnosis (Specific, Measurable, Attainable, Realistic, Timeline) Points: Points: Points: 0 (0.00%) 1 (10.00%) 2 (20.00% Does not list goals for nursing diagnosis OR goals are not in SMART format AND do not relate to the selected nursing diagnosis. Lists at least ONE goal for nursing diagnosis OR lists two goals but they are not in SMART format AND/OR do not relate to the selected nursing diagnosis. Lists TWO relate to the diagnosis. Lists One Nursing Intervention for the Selected Nursing Diagnosis Points: Points: Points: 0 (0.00%) 1 (10.00%) 2 (20.00% Does not list a nursing intervention for the selected diagnosis. Lists one nursing intervention but it is not clear how it will help the client reach the goal. Lists one nu for the sele diagnosis th client reach Summarizes Why the Intervention is Effective for the Selected Nursing Diagnosis Points: Points: Points: 0 (0.00%) 0.5 (5.00%) 1 (10.00% Does not summarize why the intervention is effective for the selected nursing diagnosis AND/OR goal. States why the intervention is effective but does not correlate it to the selected nursing diagnosis AND/OR goal. Summarize intervention selected nu and goal. Correct Grammar, Sentence Structure, and Punctuation Points: Points: Points: 0 (0.00%) 0.5 (5.00%) 1 (10.00% Has multiple grammar and/or punctuation errors throughout entire paper and sentence structure that makes it difficult for reader to understand what the writer is trying to portray. Has many grammar and/or punctuation errors as well as poor sentence structure. Has few gra punctuation Question Two In this first submission of your Course Project, you will be completing the background information on the client you selected from your clinical experience. Be sure you select a client for this project who is NOT in a terminal phase of illness/condition. This first written assignment should be 2pages pages. Include the following: Selection of Client and Background Information 1. Nursing Process

The client’s age, illness or condition, and general information about their family/significant others. Also include their gender, religion, and ethnic origin 2. Medications being taken and possible side or adverse effects Rubric Selection of Client Points: Points: Points: 0 (0.00%) 1.5 (15.00%) 3 (30.00%) DID NOT select client who is not in the terminal phase of an illness OR is able to provide personal information. Selected client who is not in the terminal phase of an illness OR is able to provide personal information BUT NOT BOTH. Selected client w terminal phase o able to provide p information. Provide Pertinent Background Information Points: Points: Points: 0 (0.00%) 3 (30.00%) 6 (60.00%) Includes LESS THAN 5 of the following: 1. Client’s age 2. Client’s illness or condition 3. Information about their family/significant others 4. Client’s gender 5. Client’s religion 6. Client’s ethnic origin 7. FIVE medications Client is taking, why they are taking them, AND possible side or adverse effects. Includes 5-6 of the following: 1. Client’s age 2. Client’s illness or condition 3. Information about their family/significant others 4. Client’s gender 5. Client’s religion 6. Client’s ethnic origin 7. FIVE medications Client is taking, why they are taking them, AND possible side or adverse effects. Includes ALL of Client’s age 2. C condition 3. Info family/significan gender 5. Client Client’s ethnic o medications Clie they are taking t side or adverse Correct Grammar, Sentence Structure, and Punctuation. Points: Points: Points: 0 (0.00%) 0.5 (5.00%) 1 (10.00%) Has multiple grammar and/or punctuation errors throughout entire paper and sentence structure that makes it difficult for reader to understand what the writer is trying to portray. Has many grammar and/or punctuation errors as well as poor sentence structure. Has a few gram punctuation erro Question Three In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following: Health Assessment, Health History, and Nursing Diagnosis 1. 2. 3. 4. A brief medical/health history Summary of laboratory diagnostic results related to the illness/condition and what they mean Summary of a head to toe physical assessment Your nursing diagnosis Rubric Provide Client Health History Points: Points: Points: 0 (0.00%) 2 (8.00%) 4 (16.00%) DID NOT provide a health history (medical, surgical, and family history) for the selected client. Provided a partial health history (medical, surgical, OR family history) for the selected client. Provided a com history (medical family history) fo client. Conduct Health Assessment and Provide Findings Points: Points: Points: 0 (0.00%) 2.5 (10.00%) 5 (20.00%) Includes ONE or LESS of the following: 1. Client vital signs 2.’ Nursing Process

Head to Toe systematic assessment and objective findings 3. Summary of laboratory diagnostic results related to the illness/condition and what they mean Includes TWO of the following: 1. Client vital signs 2. Head to Toe systematic assessment and objective findings 3.Summary of laboratory diagnostic results related to the illness/condition and what they mean Includes ALL of Client vital signs systematic asse objective finding laboratory diagn related to the illn what they mean Identify Nursing Diagnoses Points: Points: Points: 0 (0.00%) 6 (24.00%) 12 (48.00%) Correctly identifies and writes ONE or LESS NANDA nursing diagnoses that are appropriate for the selected client. Correctly identifies and writes TWO NANDA nursing diagnoses with all required parts that are appropriate for the selected client. Correctly identif THREE NANDA with all required appropriate for t Correct Grammar, Sentence Structure, and Punctuation Points: Points: Points: 0 (0.00%) 1 (4.00%) 2 (8.00%) Has multiple grammar and/or punctuation errors throughout entire paper and sentence structure that makes it difficult for reader to understand what the writer is trying to portray. Has many grammar and/or punctuation errors as well as poor sentence structure. Has a few gram punctuation erro APA format Points: Points: Points: 0 (0.00%) 1 (4.00%) 2 (8.00%) Paper contains ONE or LESS of the following: 1. Cover page 2. Reference page 3. APA headings Paper contains TWO of the following: 1. Cover page 2. Reference page 3. APA headings Paper contains following: 1. Co Reference page … Nursing Process