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NU302 Care Plan Case Study Assignment

NU302 Care Plan Case Study Assignment

Case Study Assignment Instructions
Purpose
As you are learning this semester, the role of the nurse is to integrate and apply knowledge from your general education background, health related sciences, and evidence-based nursing science in the application of the nursing process to the nursing care of patients in the acute care setting. The nurse uses knowledge from pharmacology, anatomy and physiology, pathophysiology, microbiology, nutrition, psychology, and other sciences to build a plan of care according to the health assessment findings generated by the nurse. Nursing is practiced within an interdisciplinary health care system, and it is important for the nurse to understand the perspectives of other disciplines in their contribution to the patient plan of care. For this assignment, you will use the case study provided or choose a client from your clinical rotation. You will complete an in-depth analysis of the nature of their health alterations, the pathophysiological and psychosocial aspects of their health needs and how the interdisciplinary team contributes to the treatment plan while the patient is in the hospital and as plans for discharge are put into action.
Directions
1. Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients.
2. Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient? Develop a care plan (use the template below) based on the highest priority problem (1 nursing diagnosis, 1 goal, 3 interventions for each goal, 1 rationale for each intervention and evaluation for each goal). Complete an in depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.
3. Include selected references for your case study paper/care plan and use APA format.
4. Specific grading rubric is provided.
Criteria
Case study is specific, analytical, conceptually sound and based on scientific principles and application of knowledge, reflects evidence-based nursing care approaches and science, and is holistic in its approach to understanding the patient and his/her nursing care needs.
Estimated time to complete: 6 hours
Attached Files
• Care Plan Template download[Word document]

Unit 7 Assignment: Case Study/Care Plan Paper
Student
Please find attached case study for week 7 assignment. Please follow the rubric.
Mr. Salazar, a 57-year old male, presents to the Emergency Department (ED) with chest pain. He reports that the pain started about an hour after dinner, while he was working. He describes the pain as a “crushing pressure” located midsternally and radiating down his left arm and to his back. He rates the pain a 4/10. On assessment, Mr. Salazar is diaphoretic and pale and complains of shortness of breath (SOB).
What further nursing assessments need to be performed for Mr. Salazar?
What interventions do you anticipate being ordered by the provider?
What intervention should you, as the nurse, perform right away? Why?
What medication should be the first one administered to this patient? Why? How often?
Based on the results of Mr. Salazar’s labs and his response to medications, what is the next intervention you anticipate? Why?
Required
A complete head to toe assessment
Medications
3 nursing diagnosis with 5 interventions with rationales
APA
Follow rubric
Worth 100 points

NU302 Care Plan Rubric

NU302 Care Plan Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeIntroduction to Patient
10 pts

5

Clearly explains who the patient is (age, gender, etc.), what the problem is, and what you are focusing on regarding care of this patient.

9 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

8 pts

3

Vaguely explains who the patient is, what the problem is, and what you are focusing on regarding care of this patient; missing 1 of above areas

7 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

6 pts

1

Lack of introduction to the patient; missing 2 or more areas in first 2 columns of this row.

0 pts

0

Not attempted/not submitted

10 pts
This criterion is linked to a Learning OutcomePathophysiology
10 pts

5

Clearly and concisely discusses the disease, manifestations, and causes.

9 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

8 pts

3

Vaguely or missing minimal information regarding the disease, manifestations, and causes.

7 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

6 pts

1

Missing important information regarding the disease, manifestations, and causes.

0 pts

0

Not attempted/not submitted

10 pts
This criterion is linked to a Learning OutcomeHistory
10 pts

5

Clearly and concisely discusses patient’s health history & past treatments including prior surgeries and prescribed medications.

9 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

8 pts

3

Vaguely discusses patient’s health history & past treatments including prior surgeries and prescribed medications.

7 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

6 pts

1

Missing important information regarding the patient’s health history & past treatments including prior surgeries and prescribed medications.

0 pts

0

Not attempted/not submitted

10 pts
This criterion is linked to a Learning OutcomeRelated Treatments
20 pts

5

Clearly and concisely explains what treatments the patient is receiving because of his/her disease.

18 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

16 pts

3

Vaguely explains what treatments the patient is receiving because of his/her disease.

14 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

12 pts

1

No explanation of treatment(s) patients is receiving because of his/her disease.

0 pts

0

Not attempted/not submitted

20 pts
This criterion is linked to a Learning OutcomeCare Plan
20 pts

5

Contains nursing diagnosis, 1 SMART outcome, 3 SMART interventions with appropriate rationales, and evaluation.

18 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

16 pts

3

Missing 1 part of diagnosis or 1-2 SMART outcomes and interventions; may not be the best nursing diagnosis. 1 rationale is not related to intervention.

14 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

12 pts

1

Inappropriate nursing diagnosis; lacking SMART outcomes and interventions. Rationales not supportive of interventions.

0 pts

0

Not attempted/not submitted

20 pts
This criterion is linked to a Learning OutcomeNursing Physical Assessment
20 pts

5

Clearly and concisely lists all patient’s assessment data in sentences with specific numbers/levels.

18 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

16 pts

3

Vaguely lists all patient’s assessment data; lacking some sentences; lacking some specific numbers/levels.

14 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

12 pts

1

Missing important assessment data; lacking sentences and specific numbers/levels.

0 pts

0

Not attempted/not submitted

20 pts
This criterion is linked to a Learning OutcomeAPA Formatting and References and Scholarly Writing

PRICE-I

10 pts

5

Utilizes 1st and 2nd level headings appropriately; at least 3 pages long; 2 credible resources; appropriate in text citations. Scholarly writing is evident.

9 pts

4

Contains both elements of High Proficiency and Moderate Proficiency

8 pts

3

Utilizes headings but not accurately placed; minor errors in citations and referencing. Some errors in sentence structure/grammar.

7 pts

2

Contains both elements of Moderate Proficiency and Non- Proficient

6 pts

1

Lacks headings; < 3 pages long; lacks references and in text citations. Poor grammar and sentence structure evident.

0 pts

0

Not attempted/not submitted

10 pts
Total Points: 100

 

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