Course Project Milestone #2: Nursing Diagnosis and Plan of Care Form YourName: Date: Your Instructor

 Course Project Milestone #2: Nursing Diagnosis and Plan of Care
Form
YourName: Date:
Your Instructor’s Name:
Directions:
Refer to the Milestone 2: Guidelines found in Doc Sharing to complete the
information below. This assignment is worth 300 points.
Type your answers on this form. Click “Save
as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone2_Form_Smith”.When
you are finished, submit theform to the Milestone 2 Dropbox by the deadline
indicated in your guidelines. Post questions in the Q&A Forum or contact
your instructor if you have questions about this assignment.
1: Analyze
Assessment Data:
Based on the health history information, identify the following:
A. Areas for focused assessment (15 points)
Provide
a brief overview of those areas of
strength and weakness noted from Milestone 1: Health History.
B. Client’s strengths (30 points)
Expand
on areas identified as strengths related to the person’s overall health.
Support your conclusions with data from the textbook.
C. Areas of concern (30 points)
Expand
on areas previously identified as abnormal and those that place the person at a
health risk. Support your observations with data from the textbook.
D. Health teaching topics (20 points)
Identify health education needs. Support your
statements with facts from the Health History and information from your
textbook.
2:
Physical Examination Assessment
A. Vital signs (15 points)
B/P_________P_________R _________
Please
document quality, characteristics, rate and depth:
B. Respiratory examination (30 points)
Ask
relevant respiratory history and Review of Systems questions
History of Croup or Asthma?
Y_________N_________
History of wheezing? Y_________N_________
Noisy breathing?
Y_________N_________
Shortness of breath
Y_________N_________
Chronic cough?
Y_________N_________
Exposure to cigarette smoke of
Environmental/Noxious fumes? Y_________N_________
If yes, explain_________
Most recent TB testing _________
Last Chest X Ray_________
Auscultate
all lobes for lung sounds and document below.
RUL: __________
RM: L_________
RLL: _________
LUL: _________
LLL: _________
Document
findings of the respiratory examination in Narrative Nursing Progress Notes
(type below):
C. Cardiac examination (30 points)
Ask relevant cardiac and peripheral
vascular history and review of systems questions
Any congenital heart problems?
Any history of murmur?
Any limitation of activity?
Any dyspnea on exertion?
Any history of palpitations?
Any history of high blood
pressure?
Any coldness to extremities noted?
Assess
general appearance including skin color and presence of visible pulsations
Inspect
neck for visible carotid pulses and jugular venous distention
Inspect
legs for edema and note if present:
1+ _________
2+ _________
3+ _________
Palpate
all pulses, comparing left to right
Brachial: L _________R_________
Radial: L _________R _________
Femoral: L _________R _________
Popliteal: L _________R _________
Posterior tibial: L _________R _________
Dorsal pedia: L _________R _________
Test capillary refill, comparing
left to right L _________R _________
Document
findings of the cardiac examination in Narrative Nursing Progress Notes (type
below):
D. Abdominal examination (30 points)
Ask relevant abdominal history and
Review of Systems questions, including reproductive health history questions
Any abdominal pain?
Any nausea/vomiting?
Any history of ulcer?
Frequency of bowel movements,
stool color and characteristics?
Any history of diarrhea?
History of constipation or stool
holding?
Anal itching?
History of pinworms?
Any history of use of laxatives?
Rectal Bleeding
Inspect abdomen to assess contour
and check for visible pulsations and peristalsis
Auscultate abdominal quadrants for
bowel sounds
RUQ _________
RLQ _________
LUQ _________
LLQ _________
Document findings of the abdominal examination in Narrative Nursing
Progress Notes (type below):
3: Nursing Plan of Care
Next, plan your care based on
your analysis of your assessment data:
A. NANDA Nursing Diagnosis (15 points)
Write
one nursing diagnosis that reflects
a priority need for this person. Remember a wellness diagnosis is a
possibility.
B. Plan (30 points)
Write
one goal and one measurable expected outcome related to your nursing diagnosis.
Explain why this goal and outcome is a priority. Include cultural
considerations for this client.
C. Intervention (30 points)
Write
as many nursing orders, or nursing interventions that you need in
order to achieve the outcome. Provide
the rationale for each intervention listed.
D. Evaluation (15 points)
You
will not carry out your care plan so you cannot evaluate the effectiveness of
your nursing interventions. Instead, comment on what you would look for in
order to evaluate your effectiveness.

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