Clustering Assessment Data

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Purpose of the Assignment

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  1. Assist students in clustering assessment data when developing a nursing diagnosis.
  2. Develop students’ ability to write client based outcomes when planning care.

Course Competencies

  • Explain components of multidimensional nursing care for clients with musculoskeletal disorders.

Instructions

Using the template below, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below.  Write one SMART client-centered goal for each nursing diagnosis.  Consider the client’s medical history and medications.

Riley Johnson, a 19-year-old woman, is a client on your unit due to 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.

 

 

 

 

Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
One sentence:

*Risk: Nursing diagnosis____Related to_____

*Problem: Nursing diagnosis____Related to____ as evidenced by

 

1.

One sentence:

*Risk: Nursing diagnosis____Related to_____

*Problem: Nursing diagnosis____Related to____ as evidenced by

 

2.

One sentence:

*Risk: Nursing diagnosis____Related to_____

*Problem: Nursing diagnosis____Related to____ as evidenced by

 

3.

SMART Goal SMART Goal SMART Goal
 

Goals need to be specific/measurable with a timeline, and related to nursing diagnosis

Ex. Patient will rate pain 0/10 in 30 minutes

1.

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

3.

 

Total Assessment Points – 35

Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Nursing Diagnosis (should fit the data)

(10 Pts)

Nursing diagnoses are insufficient and/or do not fit the data.

Failure to submit Nursing Diagnosis will result in zero points for this criterion.

Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data.
Points – 7 Points – 8 Points – 9 Points – 10
SMART Goal (should reflect the diagnosis and follow guidelines)

 (15 Pts)

The goals meet few SMART goal guidelines and/or are not related to the nursing diagnoses.

Failure to submit SMART goals will result in zero points for this criterion.

Writes ONE goal for ONE nursing diagnosis and the goal meets all the SMART goal guidelines and are related to the nursing diagnosis. Writes ONE goal for TWO nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses. Writes ONE goal for THREE nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.
Points – 11 Points – 12 Points – 13 Points – 15
Spelling and Grammar

 (5 Pts)

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.
Points: 2 Points: 3 Points: 4 Points: 5
APA Citation

(5 Pts)

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.
Points: 2 Points: 3 Points: 4 Points: 5

 

 

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