Get Original Solution – Conduct a sensitive patient interview using therapeutic communication skills to complete a comprehensive health history of an assigned client in the clinical setting. Do not use patient identifiers i.e. name, DOB, employer, school, etc. 2) - PaperQuest

Holistic Assessment and Application of the Nursing Process (FHP)

Objectives:

1) Conduct a sensitive patient interview using therapeutic communication skills to complete a comprehensive health history of an assigned client in the clinical setting. Do not use patient identifiers i.e. name, DOB, employer, school, etc.

2) Organize holistic data consistently using Gordon’s Functional Health Patterns as a guide.

3) Concisely summarize significant patient findings including physical, psychosocial, strengths, & weaknesses.

4) Identify one priority nursing diagnosis and correctly write it as a diagnostic statement.

5) Complete an individualized plan of care based on assessment findings and state how you would evaluate if it met patient needs.

6) Utilize self-reflection to identify health promotion opportunities and the role of the nurse.

Part I: Functional Health Pattern Data Collection and Summary

Ø This portion of the assignment will be completed on a Word document using the template below and submitted to the appropriate drop box in D2L.

Ø Students MUST use the template below and type out assignment

A. Health History by Functional Health Patterns (Human Flourishing, Nursing Judgment)

*See Medical-Surgical Nursing (Lewis et. al, 2020) Chapter 3: Health History and Physical Examination for description of each functional health pattern area as well as examples of questions to ask client. Also see assignment guide found in D2L.

Client Profile (chronological
events leading to hospitalization & progress since in your own words):

Developmental
History (identify Erickson
stage of Development with description of crisis resolution, supported by
cues):

Health Perception-Management Pattern:

Nutritional-Metabolic Pattern:

Elimination Pattern:

Activity-Exercise Pattern:

Sexuality-Reproduction Pattern:

Sleep-Rest Pattern:

Sensory-Perceptual Pattern:

Cognitive Pattern:

Role-Relationship Pattern:

Self-Perception-Self-Concept Pattern:

Coping-Stress Tolerance Pattern:

Value-Belief Pattern:

B. Summary: Bullet point out the significant health concerns, opportunities for health improvement, and client strengths/weaknesses. Summary should address psychosocial as well as physical concerns. The summary should make a case for your chosen diagnosis based on the data above.

Significant
Health Concerns:

Opportunities
for Health Improvement:

Client
Strengths/Weaknesses:

Part II: Nursing Care Plan

Ø Create a nursing care plan for your client using the table below. Be sure to include references.

A. Nursing Care Plan (Nursing Judgment) –Present data in table on concept map

Priority
Nursing Diagnosis (3-part):
_________________related to (r/t) _________________ as evidenced by (AEB) _________________

Client Goals & Outcomes

(list 2)

Nursing Interventions

(list 3 for each goal)

Evidence-based Rationale
(for each intervention – with APA in-text citation)

(Need
to be measurable with a time frame i.e.
“client will be able to list four snack choices that are in accordance with
prescribed diabetic diet prior to hospital discharge”)

(Specific
to goal i.e. “give patient a list of snacks allowed on diabetic diet”)

(Justify
intervention i.e. “giving patient a list can serve as a reminder and
reinforce teaching after discharge (Smith, 2016)”

Describe how you would evaluate the above client goals (These statements should resemble the goals and outcomes and need to be measurable and with a time frame i.e. “client will be able to list a minimum of four snack choices that are in accordance with diabetic diet prior to discharge”)

B. Reflection Questions (Nursing Judgment & Spirit of Inquiry) – Discuss each question below. Discussion needs to show evidence of depth-of-thought and reflection for each:

1) In reviewing the comprehensive history of this client, where do you see the greatest opportunities for health promotion? How does this relate to your client’s problem(s)?

2) As a nurse, what could you do that would have the greatest impact on this client’s health outcome?

3) Identify at least three insights you gained from completing this assignment and discuss each below.

Ø Insight 1:

Ø Insight 2:

Ø Insight 3:

C. List of references in APA format for sources cited in care plan

Holistic Assessment and Plan of Care Grading Rubric- 60 points

Grading Rubric: Plan of Care Assignment

Grading Criteria

10-9 points

8-7 points

6-5 points

4-3 points

2-1 points

Holistic Assessment

(10 points)

· Data is
complete and accurate from chart review and patient, & family interview.

· Subjective
data is collected through the use of sensitive inquiry.

· A
rationale is provided for data that is not provided.

· Includes
discussion of chronological events leading to hospitalization & progress
since.

· Correctly
identifies Erickson stage of Development with description of crisis
resolution, supported by cues.

· Includes
evidence of thorough body system assessment grouped in correct health
pattern.

· Each
functional area includes patient’s “normal” as well as changes occurring
since current healthcare problem.

· Assessment
is communicated factually and concisely with appropriate use of quotes

using
correct terminology and spelling.

· Data is
fairly complete and accurate from chart review and patient, & family
interview.

· Subjective
data is collected demonstrating presence of rapport.

· Includes
discussion of chronological events leading to hospitalization.

· Correctly
identifies Erickson stage of Development with description of crisis
resolution.

· Includes
evidence of some body system assessments grouped in correct health pattern,
but some objective data not collected/performed.

· Each
functional area includes only patient’s current state since healthcare
problem.

· Assessment
is clearly communicated with appropriate use of quotes.

· Generally
uses correct terminology and spelling.

· Data is
80% incomplete from chart review and patient, & family interview.

· Subjective
data is weak demonstrating lack of rapport.

· Briefly
discusses events leading to hospitalization.

· Correctly
identifies Erickson stage of Development, but fails to discuss crisis
resolution.

· Includes
evidence of basic body system assessments sometimes grouped in correct health
pattern. Some expected objective data
not present.

· Data in
functional areas varies between patient’s current state since healthcare
problem and their normal state.

· Assessment
is fairly communicated with no quotes.

· Errors
in terminology and spelling present

· Incomplete
data (70%) from chart review and patient & family interview.

· No
rationale for omitted data.

· There
is an absence of sensitive inquiry reflected in the absence of subjective
data.

· Omission
or inaccurate identification of stage of development with little or no
supporting data.

· Incomplete
summarization of body system assessment.

· Areas
are minimally addressed.

· Few
descriptions of general assessment.

· Lacks
organization of data within correct health pattern.

· Includes
opinion with no supporting data

· Does
not meet criteria for professional submission with frequent errors in
spelling and terminology.

· Data
very incomplete, less than 70%

· Multiple
health pattern areas have no data.

· Areas
addressed have 1-2 lines of data.

· No
evidence of own physical assessments present

· Data is
poorly presented.

Summary

(10 points)

· Accurately
summarizes all significant physiological & psychosocial findings.

· Includes
strengths as well as weaknesses.

· Summary
is logically organized and concisely tells the patient’s “story”.

· Summary
leads to development of priority nursing diagnosis.

· Accurately
summarizes most (80%) significant physiological & psychosocial findings,
but misses some relevant cues.

· Greater
emphasis on weaknesses, but recognizes at least one strength.

· Summary
is fairly well-organized.

· Contributes
to identification of logical nursing diagnosis.

· Summarizes
at least 70% of findings.

· Includes
only physiological findings.

· Discusses
only weaknesses.

· Summary
is somewhat organized.

· Summary
leads to identification of a nursing diagnosis, but not best choice.

· Several
significant findings (50% or more) were not summarized.

· Discussion
of identified strengths and weakness absent or inaccurate.

· Summary
does not lead to accurate development of priority nursing needs.

· Fails
to complete or summary very brief and excludes the majority of significant
findings.

· Focus
on physical needs only.

· No
discussion of strengths.

· Not
useful in determining priority nursing needs.

Nursing Diagnosis

(10 points)

· Uses
summary to correctly identify a priority problem from data presented.

· Diagnosis
is a complete3-part statement (problem, etiology, & signs/symptoms) using
correct NANDA terminology and format.

· Uses
summary to correctly identify a significant problem from data presented, but
not necessarily priority.

· Diagnosis
is a complete3 or 2-part statement (problem, etiology, & signs/symptoms)
with only minor errors in correct NANDA use.

· Inaccurately
interprets data presented so problem identified is not appropriate for the
client.

· Attempts
to write diagnosis as a 3 or 2-part statement (problem, etiology, &
signs/symptoms), bu multiple errors in correct NANDA use.

· The
nursing diagnosis selected reflects minimal analysis or inaccurate
interpretation of assessment information.

· Incompletely
written, does not contain all of the elements of a 3 or 2-part NANDA
diagnostic statement.

· Diagnosis
chosen is not accurate and does not reflect a priority nursing need for the
client based on the data.

· Only
the diagnostic label is presented with no attempt to complete the diagnostic
statement.

Goals/ Evaluation

(10 points)

· Correctly
writes two goals using the 5-part statement (subject, measureable verb,
condition, criteria, time frame).

· One
goal may be missing a single element.

· Goal is
individualized, realistic for patient, and focuses on resolution of
problem.

· Each is
written in the appropriate domain (cognitive, affective, or psychomotor) for
problem resolution and includes a single outcome.

· The
evaluation describes evaluative criteria appropriate for the domain that
would determine if goal was or was not met.

· Evaluates
the goal as written.

· Both
goals are missing one part of the 5-part statement (subject, measureable
verb, condition, criteria, time frame). OR-

· Attempts
to individualize goal but criteria may not be realistic for patient, or focus
on resolution of problem.

· May not
be written in the appropriate domain (cognitive, affective, or psychomotor)
OR

· includes
more than one outcome.

· Evaluation
of one goal describes evaluative criteria appropriate for the domain that
would determine if goal was or was not met, but 2^nd evaluation
does not and may add criteria not evident in the goal.

· Both
goals are missing more than one part of the 5-part statement (subject,
measureable verb, condition, criteria, time frame).

· Attempts
to individualize goal but criteria may not be realistic for patient, or focus
on resolution of problem.

· Not
written in the appropriate domain (cognitive, affective, or psychomotor).

· Goals
include more than one outcome.

· Neither
evaluation correctly evaluates criteria as stated in the goal.

· Evaluation
is inconsistent with domain or adds criteria not evident in goal.

· Goals
are incomplete and do not have 5 parts of well-written goals or did not
select measurable verb.

· Not
realistic or individualized.

· Goal is
not directed toward resolution of the problem.

· Does
not state evaluative criteria that would be used to measure goal achievement.

· Evaluates
the interventions rather than the goal, establishing criteria not evident in
the goal.

· Includes
outcomes as written in resources, with no attempt to write as a complete
statement or individualize for the patient.

· Does
not address evaluation or statements have no direct connection to goals as
written. OR

· Unable
to accurately evaluate because of errors in goals.

Interventions/Rationales

(10 points)

· Identifies
three evidence-based, patient-centered nursing actions appropriate to achieve
each goal.

· Interventions
are personalized, realistic, & written with sufficient detail to direct
care of the health care team.

· Rationales
are provided for each intervention.

· Rationales
are comprehensive, theory-based, with citation of source.

· Rationales
clearly and succinctly identify why the intervention represents best practice
& how it contributes to goal achievement.

· Identifies
at least 2 evidence-based, patient-centered nursing actions for each goal,
but other intervention does not meet criteria.

· Interventions
are personalized but not written with sufficient detail to direct care of the
health care team.

· Rationales
are provided for each intervention.

· Rationales
are comprehensive but not always theory-based.

· Rationales
identify why the intervention was selected and implies how it contributes to
goal achievement.

· Some
interventions are evidence-based and patient-centered, but the majority are
not.

· Interventions
are not personalized and lack sufficient detail to direct the care of the
health care team.

· Rationales
are provided for most interventions.

· Citations
are provided on at least half.

· Many
rationales lack substance with insufficient evidence of theory reflected.

· Rationale
does not clearly state how the intervention influences goal achievement.

· The
list of interventions is not complete, not patient-centered, or not based on
current evidence.

· Interventions
are not related to the goal or are not nursing actions.

· Rationales
are shallow, not based on scientific theory.

· Does
not provide rationales for all interventions.

· Rationales
lack citation of source.

· Lists
nursing actions verbatim from resources with no attempt to personalize or
develops them without reference to resources.

· Rationales
are restatements of interventions linked to goal without reference to theory
stating how it exerts its effect.

· No
citations present.

Reflection

(10 points)

· Strong
evidence of reflective thought.

· Thoughtfully
considers individualized health promotion opportunities based on patient
history.

· Is
clearly able to articulate how to effectively intervene to impact patient’s
healthcare outcomes.

· Thoughtfully
reflects on how providing care, interacting with the client, completing the
assessment and plan of care contributed to professional growth.

· Thoughts
are logically, & professionally articulated.

· Fair
degree of reflection present.

· Considers
health promotion opportunities appropriate for client’s diagnosis.

· Provides
suggestion on how to intervene to impact patient’s healthcare outcomes.

· Lists
what was learned by providing care, interacting with the client, completing
the assessment and plan of care.

· Thoughts
are clearly articulated and well-organized.

· Insufficient
evidence of reflective thought.

· Does
not completely address all questions.

· Considers
one health promotion opportunity for persons with this diagnosis.

· Vaguely
states how one might intervene for an individual with this diagnosis.

· Briefly
states what was learned by completing this assignment- doesn’t address all
aspect of learning opportunities.

· Only
brief statements per question with minimal evidence of reflective
thought.

· Addresses
2 of 3 questions.

· Discusses
care provided, but unable to relate to personal growth

· Addresses
1 of 3 questions.

· The
question addressed does not demonstrate evidence of the ability to
self-reflect and thoughtfully consider the experiences of others.

· Does
not state how assignment contributes to personal growth.

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