Purpose:

To demonstrate ability to creatively integrate the nursing process, broad professional issues, and curriculum threads with care of a client/family.

Content:

1. Introductory paragraph (4 points) explaining the purpose and organization of the paper as well as introducing the client. (Remember: do not include any identifying characteristics of the client.)

2. Data base and assessment (14 points): Use the clinical Health Assessment format and record the data you obtained from your client assessment. Include information about significant diagnostic and laboratory testing.
3. Client’s medications: List and discuss the client’s medication and how they relate to the client’s overall plan of care and pertinent nursing implications. (8 points)

4. Client learning needs (8 points): focus on a minimum of one specific situation in which client learning needs were identified

–          Identify what the patient wants/needs to learn as well as factors that indicate his/her readiness to learn.

–          Identify other factors that will impact client including any physical, environmental, and/or experiential factors that may influence the client’s learning.

5. Describe the pathophysiology of the client’s primary medical/surgical diagnosis and correlate it with the client’s clinical manifestations and diagnostic findings.(10 points)

6. Integration of curricular threads (4 points): Discuss how you integrated one (1) of the following curriculum threads (leadership, management, adaptation, advocacy) into the planning, interventions, and evaluation of the client’s care.
7. Research (8 points): Briefly discuss applicable primary nursing research and integrate it into the client/family situation. Describe how and why it is appropriate for this case. Must submit a copy of the nursing research article with your paper.
8. List client’s nursing diagnoses using PES (Problem, Etiology, Signs and Symptoms ) andformat in order of priority; include a “knowledge deficit” diagnosis (8 points).

Plan of Care: Develop a plan of care for 2 of the identified nursing diagnoses. One of the nursing diagnoses must be a “knowledge deficit” diagnosis related to your client’s learning needs (see above).

1. Provide expected outcomes that are realistic, measurable and time framed (3 points).

1. Develop nursing orders related to each nursing diagnosis and expected outcomes.A variety of interventions should be presented including assessment activities as well as direct care measures. Include collaborative measures and multidisciplinary team members where appropriate (8 points).

1. State rationales for each intervention that are scientific and referenced (8 points).

1. Evaluation (4 points): Evaluate (1) whether the expected client outcomes were met and (2) your implementation of nursing orders (interventions) and (3) explain any that were not met. Describe changes in interventions that could be implemented as a result of the evaluation.

8. Summary: Briefly summarize pertinent information and what you learned from this experience (3 points).

Format and writing

9. Communication (5 points): The paper should be clearly presented, well-organized, with correct grammar, spelling and punctuation. Ideas should be presented logically and in a style that flows and is understandable

10. Documentation (5 points): A minimum of 6 appropriate references published within the last 5 years should be used. APA style and format should be used for this paper. The paper should be typed, double spaced, and no more than 24 pages in length excluding title page and bibliography. A paper greater than 24 pages total will have 3 points per excessive page deducted.