Purpose of the Assignment
1. Assist students in clustering assessment data when developing a nursing diagnosis.
2. Develop students’ ability to write client based outcomes when planning care.
· Explain components of multidimensional nursing care for clients with musculoskeletal disorders.
Using the template below the instructions, write 3 nursing diagnoses in proper format based on the client case provided below. Write one SMART client-centered outcome for each diagnosis. Consider the client’s medical history and medications.
Kacie Benson, a 19 year-old woman, is a client on your unit as a result of a skiing accident. She is unconscious and may or may not regain consciousness. She is on complete bedrest. She requires frequent repositioning to maintain correct body alignment and attention to her ROM. She responds to painful stimuli with slight non-purposeful withdrawal. No spontaneous movements are noted. The recent lower extremity ultrasound showed no evidence of venous thrombosis and she continues on low molecular weight heparin injections. Her fluid and electrolyte balance is being maintained by a tube feeding at 60 mL per hour continuously. She is incontinent of stool and has an indwelling Foley catheter. Her heels are reddened, but otherwise her skin is intact.
Use at least two scholarly sources to support your nursing diagnoses. Be sure to cite your sources in-text and on a reference page using APA format
Module 04 Written Assignment – Nursing Diagnosis Rubric
Total Assessment Points – 35
|Levels of Achievement
|Nursing Hypothesis/Diagnosis (should fit the data)
|Nursing hypothesis/diagnosis is insufficient and/or does not fit the data.
|Writes nursing hypothesis/diagnosis in the correct format with little connection to identified data.
|Writes nursing hypothesis/diagnosis in the correct format with an adequate connection to identified data.
|Writes nursing hypothesis/diagnosis in the correct format with a strong connection to identified data.
|Points – 0-7
|Points – 8
|Points – 9
|Points – 10
|SMART Goal (should reflect the diagnosis and follow guidelines)
|The goal meets few SMART goal guidelines and/or is not related to the nursing diagnosis.
|The goal meets some of the SMART goal guidelines and is related to the nursing diagnosis.
|The goal meets most of the SMART goal guidelines and is related to the nursing diagnosis.
|The goal meets all of the SMART goal guidelines and is related to the nursing diagnosis.
|Points – 0-11
|Points – 12
|Points – 13
|Points – 14-15
|Spelling and Grammar
|Numerous spelling and grammar errors, which detract from the audience’s ability to comprehend material.
|Some spelling and grammar errors, which detract from the audience’s ability to comprehend material.
|Few spelling and grammar errors.
|Minimal to no spelling and grammar errors.
|APA in-text citations and references are missing.
|Attempted to use APA in-text citations and references.
|APA in-text citations and references are used with few errors.
|APA in-text citations and references are used correctly.