Topic:Care Plan, Learning Plan and Self Assessment test
Subject:Nursing
Volume: 4 pages
Type: Other
Format: APA
Description
There are 4 template pages provided for you. You will look at the assignment guidlines document and read the case study about the client. You will then fill in the templates based on the information provided about the client. The Care plan document has 1 page template to be filled out at the end of the document. The interventions part of the care plan is the ONLY part that will need to be referenced using accredited nursing journals or sources, no later than 5 years old in APA format. The Learning Plan document has a 2 page template to be filled out at the end of the document. The Self Assessment document has 1 page template to be filled out at the end of the document. AGAIN please refer to the guidelines document for a detailed outline of the assignment guidelines and in each document attached after that it will show you examples on how each template should be completed.
Assignment
Your Assignment:
1. Review the case study below.
2. Use the Nursing Care Plan template below to complete a care plan for Ms. Smith as follows:
Identify 2 nursing diagnosis 2 marks
Indicate what assessment data supports each of your diagnosis. 2 marks
List 1 goal/plan statement for EACH nursing diagnosis. 2 marks
Identify 2 nursing interventions for each goal/plan statement 4 marks
3. Using the 5 Practice Concepts and associated Practice Components attached and based on the care needs of this client identify 4 of your strengths and 4 areas for improvement. Please be specific . Ask a peer to complete the Peer Assessment section based on his/her knowledge of your skills and abilities. Both of you are required to sign the sheet. 4 marks
4. Based on your self and peer assessment AND the care needs of your client complete 2 learning plans using the approved format. 6 marks
Assignment Guidelines:
1. Format: typed, double-spaced with cover page and reference page .
2. Worksheet: may be hand written or word processed but must be legible.
3. Please note: marks assigned for each question include a component for scholarly writing. (spelling, grammar, referencing, clarity etc.)
4. This assignment is to be completed in pairs. You must EACH individually complete section #4 and # 5.
An actual problem is one that is present……
pain, nausea, skin breakdown, impaired vision etc….
A potential problem is one that may occur……
RISK for falls, risk for dehydration, risk for skin
breakdown etc…
How to write a nursing diagnosis.
2 or 3 part statement
1.Problem – needs to be described clearly
2.etiology (cause)
3.defining characteristics – additional information
that will further clarify or validate the diagnosis,
may be subjective/objective or both.
• purpose is to describe the problem as clearly as possible
Guidelines for writing nursing diagnosis.
1.Check to make sure that the patients problem precedes the
etiology & that the 2 are linked by the phrase “related to or due to or associated with”
2.Make sure you’re not simply repeating the “problem” as
the “etiology”
3.Defining characteristics, if included, should follow the
etiology and be linked by the phrase “as evidenced by or
as manifested by”
4.Write in legally advisable terms
5. Use nonjudgmental language
6. Avoid using defining characteristics, Do not use medical diagnosis or something that cannot be changed
DIAGNOSIS EXAMPLES…..
•pain due to broken leg
•anxiety associated with hospitalization
•ineffective airway clearance due to COPD
•anxiety due to SOB
•impaired circulation due to prolonged bed rest
•risk for pneumonia due to prolonged bed rest as manifested by ineffective cough
•risk for anxiety associated with recent divorce
You will write the nursing diagnosis based on the client in the case study provided in the assignment guideline.
Writing plan/goal statements…..
• always start with “the client will…..”
• include a verb
• special conditions
• performance criteria
• target time or date
Use the SMART Criteria
“S”pecific
“M”easurable
“A”chievable
“R”ealistic/relevant
“T”imed
Plan statement examples…
• pt will report pain less than 3 on VAS by 1400 hrs
• pt will report reduced anxiety by end of shift
• pt O2 sats will increase to 90% within 4 hours of O2 by NP at 2 L/min
• pt will not experience any skin breakdown while in hospital
Stating Interventions……..
• must be directly related to the desired outcome
• clear and concise description of the nursing actions
• includes who, what, when, where, how
• dated and timed
• usually written in a step by step manner and numbered
Need to be “SMART “
6 steps to choosing interventions
• Review the nursing diagnosis
• Consider the goals and expected outcomes
• Use evidence based practice ie research and BPG’s (YOU WILL NEED TO USE PROFESSIONAL JOURNALS and accredited sources, to write the nursing interventions)
• Think about feasibility
• Consider acceptability to the client
• Your own competence
