Instructions 1. Review the rubric to make sure you understand the criteria for earning your grade. 2. In your textbook, Physical Examination and Health Assessment, read: a. Chapter 1: Evidence-Based Assessment
b. Chapter 2: Cultural Assessment 3. Download and review the Nursing Process PowerPoint presentation. 4. Access an additional resource available to you to help with creating care plans, an ebook from the OCLS collection, Nursing Diagnosis Handbook. There are several editions of this book available. Simply search the title. You may utilize other Nursing Diagnoses books that you may have. 5. Utilizing the format in the Care Plan Table, prepare to discuss the following prompts: a. Think of a client you have cared for in the past weeks or months. Without breaching HIPAA regulations, what health-related nursing problems did you identify in your assessment that went beyond the medical diagnosis but were in the realm of nursing? Describe the subjective and objective data you assessed, dividing the data into the five realms of the client (physical, spiritual, developmental, cultural, and psychosocial). b. Develop a minimum of one priority nursing diagnosis utilizing the data from the assessment you identified. Your nursing diagnosis must be an actual problem and should, therefore, include the NANDA label, etiology (related to), and defining characteristics (the subjective and objective data.) Include a brief explanation (two or three lines) to describe why you chose this nursing diagnosis. c. Construct one short-term SMART outcome. d. Identify three nursing interventions that would help the client accomplish the goal, along with scientific rationales for each intervention, as to why the intervention was indicated. The resource mentioned above (#4) offers a good starting point for identifying evidence-based nursing interventions and scientific rationales. 6. Find at least two current scholarly sources to support your explanations and insights. OCLS resources are preferred sources and can be accessed through IWU Resources. Wikipedia is not permitted, as it is not a peer-reviewed, scholarly source.
