Adult Gerontology Health Nursing I Clinical Care Plan
Order ID |
53563633773 |
Type |
Essay |
Writer Level |
Masters |
Style |
APA |
Sources/References |
4 |
Perfect Number of Pages to Order |
5-10 Pages |
Description/Paper Instructions
Science and Wellness School of Health Professions
Nursing Department
Clinical Care Strategy
I’m a nurse who specializes in adult gerontology and health care.
2017 Spring
Allergies: is my height.
The First Section
Data in general
(Number 5)
The Main Complaint:
(Detailed) History of Current Illness:
Medical/Surgical Background:
History of Society:
Illness in the family history:
History of Immunization:
Procedures (surgeries) performed during this admission:
The Second Section
Pathophysiology
(Number 10)
The student must address a description of the disease process, including origin, pathophysiology, signs and symptoms, and typical therapy, such as medicine, surgery, and so on, in this section. (Use this section to summarize the textbook explanation of the ailment and compare it to the patient’s description of his or her disease.) At the end of the care plan, provide a reference page.)
Section Three
Assessment
(Points 20 and 21)
Physical Examination:
Appearance in general
Neurosensory
Psychosocial
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Incisions
Drains
Diet/Nutrition
IVs
Signs of Life
Output and Intake
Assessment of Pain (include reassessment)
Risk Assessment for Fall (include score)
Risk Assessment for Pressure Ulcers (include score)
Section Four
Diagnostic Data
(Points 10)
Diagnostic Tests |
Patient’s value |
Normal Range |
Inference(why is this patients value abnormal) |
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Section V
Treatment and procedures
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
(Points 10)
Section VI
Teaching and Health Promotion
(Points 5)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
1)
2)
3)
4)
5)
Section VII
(Points 5)
List of Nursing Diagnoses Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)
1)
2)
3)
4)
Section VIII
Medications
(Points 10)
Medication Sheet
Medication Dose
Brand/
Generic Name |
Mechanism of Action/Indication for Use |
Contraindication |
Adverse Effects/Side Effects |
Nursing Implications
|
Outcomes |
Safe Dose
(yes or no)
Why is your client on the drug? |
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Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES
Assessment
findings |
Nursing Diagnosis
(Actual & Potential Deficits, Wellness Diagnoses) |
Outcomes
Short and Long Term |
Interventions/Nursing Systems
(Dependent & Independent) |
Rationale
(Why are performing that intervention?) |
Evaluation/Outcome
(What was the actual result?) |
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School of Health Professions, Science and Wellness
Department of Nursing
Clinical Care Plan
Adult Gerontology Health Nursing I
Spring, 2017
Student: _________________________________ Date: ______________________________
Instructor: ______________________________ Clinical Course: ______________________
Client’s Initials: ___________ Age: _________ Sex: ________ Room#: ________________
Date of Admission: ________________ Date of Care: _____________________________
Present Medical Diagnoses: ____________________________________________________
Present Surgery (if applicable): _____________________ Date of Surgery: ______________
Allergies: __________________________ Height: ________ Weight: _________
Code Status: ________________________
Section I
General Data
(Points 5)
Chief Complaint:
History of Present Illness (Detailed):
Past Medical/Surgical History:
Social History:
Family History of Illness:
Immunization History:
Description of Procedures (Surgeries) Performed this Admission:
Section II
Pathophysiology
(Points 10)
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan )
Section III
Assessment
(Points 20)
Physical Assessment:
General Appearance
Neurosensory
Psychosocial
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Incisions
Drains
Diet/Nutrition
IVs
Vital Signs
Intake and Output
Pain assessment (include reassessment)
Fall Risk Assessment (include score)
Pressure Ulcer Risk Assessment (include score)
Section IV
Diagnostic Data
(Points 10)
Diagnostic Tests |
Patient’s value |
Normal Range |
Inference(why is this patients value abnormal) |
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Section V
Treatment and procedures
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
(Points 10)
Section VI
Teaching and Health Promotion
(Points 5)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
1)
2)
3)
4)
5)
Section VII
(Points 5)
List of Nursing Diagnoses Use your assessment, the client’s medications and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)
1)
2)
3)
4)
Section VIII
Medications
(Points 10)
Medication Sheet
Medication Dose
Brand/
Generic Name |
Mechanism of Action/Indication for Use |
Contraindication |
Adverse Effects/Side Effects |
Nursing Implications
|
Outcomes |
Safe Dose
(yes or no)
Why is your client on the drug? |
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|
|
|
|
|
|
Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “ 3 ” (MINIMUM) NURSING DIAGNOSES
Assessment
findings |
Nursing Diagnosis
(Actual & Potential Deficits, Wellness Diagnoses) |
Outcomes
Short and Long Term |
Interventions/Nursing Systems
(Dependent & Independent) |
Rationale
(Why are performing that intervention?) |
Evaluation/Outcome
(What was the actual result?) |
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RUBRIC
QUALITY OF RESPONSE |
NO RESPONSE |
POOR / UNSATISFACTORY |
SATISFACTORY |
GOOD |
EXCELLENT |
Content (worth a maximum of 50% of the total points) |
Zero points: Student failed to submit the final paper. |
20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. |
30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. |
40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. |
50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. |
Use of Sources (worth a maximum of 20% of the total points). |
Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. |
5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. |
10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. |
15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. |
20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. |
Grammar (worth maximum of 20% of total points) |
Zero points: Student failed to submit the final paper. |
5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors |
10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors |
15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. |
20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. |
Structure of the Paper (worth 10% of total points) |
Zero points: Student failed to submit the final paper. |
3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. |
5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper |
7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. |
10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper. |
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