Module 04 Written Assignment – Nursing DiagnosisPurpose of the A

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 to 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, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below. Write one SMART client-centered goal for each nursing diagnosis. Consider the client’s medical history and medications. Riley Johnson, a 19-year-old woman, is a client on your unit due to 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. Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 1. One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 2. One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 3. SMART Goal SMART Goal SMART Goal Goals need to be specific/measurable with a timeline, and related to nursing diagnosis Ex. Patient will rate pain 0/10 in 30 minutes 1. 2. 3. Module 04 Written Assignment – Nursing Diagnosis Rubric Total Assessment Points - 35 Levels of Achievement Criteria Emerging Competence Proficiency Mastery Nursing Diagnosis (should fit the data) (10 Pts) Nursing diagnoses are insufficient and/or do not fit the data. Failure to submit Nursing Diagnosis will result in zero points for this criterion. Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Points – 7 Points – 8 Points - ...

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 to 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, write 3 NANDA-I approved nursing
diagnoses in a proper format based on the client case provided
below. Write one SMART client-centered goal for each nursing
diagnosis. Consider the client’s medical history and
medications.
Riley Johnson, a 19-year-old woman, is a client on your unit
due to 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 incontine nt 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.
Nursing Diagnosis
Nursing Diagnosis
Nursing Diagnosis
One sentence:
*Risk: Nursing diagnosis____Related to_____
*Actual: Nursing diagnosis____Related to____ as evidenced by
1.
One sentence:
*Risk: Nursing diagnosis____Related to_____
*Actual: Nursing diagnosis____Related to____ as evidenced by
2.
One sentence:
*Risk: Nursing diagnosis____Related to_____
*Actual: Nursing diagnosis____Related to____ as evidenced by
3.
SMART Goal
SMART Goal
SMART Goal
Goals need to be specific/measurable with a timeline, and
related to nursing diagnosis
Ex. Patient will rate pain 0/10 in 30 minutes
1.
2.
3.
Module 04 Written Assignment – Nursing Diagnosis Rubric
Total Assessment Points - 35
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Nursing Diagnosis (should fit the data)
(10 Pts)
Nursing diagnoses are insufficient and/or do not fit the data.
Failure to submit Nursing Diagnosis will result in zero points
for this criterion.
Writes ONE NANDA-I approved nursing diagnosis in the
correct format (including related to/as evidenced by) with a
strong connection to identified data.
Writes TWO NANDA-I approved nursing diagnoses in the
correct format (including related to/as evidenced by) with a
strong connection to identified data.
Writes THREE NANDA-I approved nursing diagnoses in the
correct format (including related to/as evidenced by) with a
strong connection to identified data.
Points – 7
Points – 8
Points - 9
Points - 10
SMART Goal (should reflect the diagnosis and follow
guidelines)
(15 Pts)
The goals meet few SMART goal guidelines and/or are not
related to the nursing diagnoses.
Failure to submit SMART goals will result in zero points for
this criterion.
Writes ONE goal for ONE nursing diagnosis and the goal meets
all the SMART goal guidelines and are related to the nursing
diagnosis.
Writes ONE goal for TWO nursing diagnoses and the goals meet
all the SMART goal guidelines and are related to the nursing
diagnoses.
Writes ONE goal for THREE nursing diagnoses and the goals
meet all the SMART goal guidelines and are related to the
nursing diagnoses.
Points – 11
Points - 12
Points - 13
Points – 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: 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: 2
Points: 3
Points: 4
Points: 5
Module 04 Written
Assignment
–
Nursing Diagnosis
Purpose of the Assignment
1.
Assist students in
clustering
assessment data
when
develop
ing
a
nursing diagnosis.
2.
Develop students’ ability to 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,
w
rite 3
NANDA
-
I
approved
nursing diagnoses in
a
proper format
based on the client case provided below. Wri
te one SMART
client
-
centered
goal
for each
nursing
diagnosis. Consider the client’s medical history and
medications.
Riley Johnson
, a 19
-
year
-
old woman, is a
client
on your unit
due to
a skiing accident. She
is unconscious and may or may not regain consc
iousness. 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 recen
t 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.
Nursing Diagnosis
Nursing Diagnosis
Nursing Diagnosis
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 to write client based outcomes
when planning care.
Course Competencies
clients with musculoskeletal
disorders.
Instructions
Using the template below, write 3 NANDA-I approved nursing
diagnoses in a proper format
based on the client case provided below. Write one SMART
client-centered goal for each
nursing diagnosis. Consider the client’s medical history and
medications.
Riley Johnson, a 19-year-old woman, is a client on your unit
due to 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.
Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Module 04 Written Assignment – Nursing DiagnosisPurpose of the A

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Module 04 Written Assignment – Nursing DiagnosisPurpose of the A

  • 1. 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 to 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, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below. Write one SMART client-centered goal for each nursing diagnosis. Consider the client’s medical history and medications. Riley Johnson, a 19-year-old woman, is a client on your unit due to 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 incontine nt 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.
  • 2. Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 1. One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 2. One sentence: *Risk: Nursing diagnosis____Related to_____ *Actual: Nursing diagnosis____Related to____ as evidenced by 3. SMART Goal SMART Goal SMART Goal Goals need to be specific/measurable with a timeline, and related to nursing diagnosis Ex. Patient will rate pain 0/10 in 30 minutes 1.
  • 3. 2. 3. Module 04 Written Assignment – Nursing Diagnosis Rubric Total Assessment Points - 35 Levels of Achievement Criteria Emerging Competence Proficiency Mastery Nursing Diagnosis (should fit the data) (10 Pts) Nursing diagnoses are insufficient and/or do not fit the data. Failure to submit Nursing Diagnosis will result in zero points for this criterion. Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Points – 7 Points – 8 Points - 9 Points - 10 SMART Goal (should reflect the diagnosis and follow
  • 4. guidelines) (15 Pts) The goals meet few SMART goal guidelines and/or are not related to the nursing diagnoses. Failure to submit SMART goals will result in zero points for this criterion. Writes ONE goal for ONE nursing diagnosis and the goal meets all the SMART goal guidelines and are related to the nursing diagnosis. Writes ONE goal for TWO nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses. Writes ONE goal for THREE nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses. Points – 11 Points - 12 Points - 13 Points – 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: 2 Points: 3 Points: 4 Points: 5 APA Citation (5 Pts) APA in-text citations and references are missing.
  • 5. 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: 2 Points: 3 Points: 4 Points: 5 Module 04 Written Assignment – Nursing Diagnosis Purpose of the Assignment 1. Assist students in clustering assessment data when develop ing a nursing diagnosis. 2. Develop students’ ability to write client based outcomes when planning care.
  • 6. Course Competencies · Explain components of multidimensional nursing care for clients with musculoskeletal disorders. Instructions Using the template below, w rite 3 NANDA - I approved nursing diagnoses in a proper format based on the client case provided below. Wri te one SMART client - centered goal for each nursing
  • 7. diagnosis. Consider the client’s medical history and medications. Riley Johnson , a 19 - year - old woman, is a client on your unit due to a skiing accident. She is unconscious and may or may not regain consc iousness. 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 recen t 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
  • 8. 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. Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis 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 to write client based outcomes when planning care. Course Competencies clients with musculoskeletal disorders.
  • 9. Instructions Using the template below, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below. Write one SMART client-centered goal for each nursing diagnosis. Consider the client’s medical history and medications. Riley Johnson, a 19-year-old woman, is a client on your unit due to 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. Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis