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Course Project Milestone #2: Nursing Diagnosis and Plan of Care Form

Your Name:                                                                                        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 250 points, with 10 points awarded for clarity of writing, which means the use of proper grammar, spelling, and medical language.

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 the form 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:

1. Areas for focused assessment (30 points)

Provide a brief overview of those areas of strength and weakness noted from Milestone 1: Health History.

First, an area of strength is that the patient believes in the science behind disease causation, and thus has nothing against healthcare intervention through medication. Second, another area of strength is how she is the breadwinner of her family, and thus always strives to maintain her good health. Third, there is also strength since she is covered by the Medicaid Insurance program, hence she will not fail to get medication. Fourth, the fact that she has attained a Diploma is also strength as she has the required knowledge to understand importance of medical interventions. Fifth, she is employed, and thus can manage to maintain a healthy lifestyle if properly advised. Weaknesses, on the other hand, are; first, her occupation as a cashier may expose her to certain medical conditions since she is expected to constantly sit at a desk and receive cash. Second, the strong belief she has in family may hinder her from getting the medical attention she needs as her relatives may not be for the idea of treatment. Third, there is also a weakness when considering the fact that she consumes a lot of fast foods that are high in calories. Fourth, the loneliness she suffers from due to divorce also predisposes her to various health dangers. Fifth, she has been performing incomplete physical exercises that involve only the extremities; hence she is not really helping her situation but only making it worse. Lastly, her parents have both suffered from various genetic diseases, which they may have obtained from the grandparents who have also had their fair share.

1. 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.

The strengths of this patient are based on the fact that she is knowledgeable when it comes to considering how individuals contract illnesses; she understands the importance of good health in performing well at work; and can obtain the financial support she requires. All these are aspects that have been noted to influence whether or not a patient will accept medical intervention (Tartaglia, 1985). In the case of D.S, nothing is standing in her way to prevent her use of medical services as needed.

1. 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.

Her occupation, genetics, mental and physical state are what are placing her at risk health wise. This is because they predispose her to various illnesses, which may have been avoided in their absence (Tartaglia, 1985). For instance, she has most likely inherited the genes associated with coronary artery disease from her father.

1. Health teaching topics (30 points)

Identify health education needs. Support your statements with facts from the Health History and information from your textbook.

From the history, she follows an extreme exercise routine which is incomplete; therefore she strains her muscles, as she does not follow all the exercising requirements.  Hence, she needs to be educated on the right exercise routine which will promote good health instead of create more health risks (Müller-Staub et al., 2007). Second, she needs to be educated on a healthy diet, as she has a history of consuming too much fast food that is high in calories.

2: Nursing Plan of Care

Next, plan your care based on your analysis of your assessment data:

1. Diagnosis (30 points)

Write one nursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.

Considering her symptoms, she may be showing symptoms of a myocardial infarction as evidenced by the experience of neck pain, back pain, chronic depression and carpal tunnel. All these factors are symptoms of the medical condition. Her history of consuming high calories also supports this diagnosis as she may have destroyed the condition of her arteries already.

1. 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.

A goal related to the diagnosis is to stop the consumption of fast foods, and instead consider the consumption of healthy meals that have been prepared at home. The outcome is that the fat deposits in her arteries will reduce, thus encouraging sufficient blood flow as required. This is a priority as the body cannot be healthy, or in a state to exercise, while not getting sufficient oxygen.

1. 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.

First, there is a need to educate the patient on the dangers of her diet, and thus help her develop a new healthier plan. The patient will not stick to the new plan unless she understands the implications it will have on her general health.  Second, the patient needs to be given an order to exercise for 30 minutes, at least three times a week. Third, she needs to get medical checkups frequently, at least once a month so as to analyze her progress.

1. Evaluation (30 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.

There are various factors that I would consider when evaluating the effectiveness of these interventions. First, weight loss is a good indicator as it means there is no extra fat being stored in the body. Second, I would consider the health status at present, how she feels, and if the symptoms are worsening or disappearing. Third, a medical exam to actually check her arteries will also be a good indicator of whether the interventions have been effective or not.