Fundamentals project

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In this second submission of your Course Project, you will be completing a health history, physical assessment of your client and determining their nursing diagnoses. This written assignment should include the following:

Health Assessment, Health History, and Nursing Diagnosis

  1. A brief medical/health history
  2. Summary of laboratory diagnostic results related to the illness/condition and what they mean
  3. Summary of a head to toe physical assessment
  4. Your nursing diagnosis

FUNDAMENTALS COURSE PROJECT WINTER 2022 (group)

Course Project Instructions

On week 2 or 3, you will be assigned a group and a case study. You will submit one paper as a group. Make sure all names are included on the paper. Your project will be submitted as a formal (APA) paper. You will submit this paper in three parts. Submit the whole paper (what is due) on the due dates. For example: on week 5, submit what is required (part 1); on week 7, submit what you already submitted on week 5 plus the completed sections that you added to the paper (part 1 and 2); and on week 10, you will submit the complete paper (parts 1, 2, and 3).
If you do not submit the project as a paper, you will be penalized 50% for each part
. Use the medication template and the nursing care plan templates below (upload into your paper). Note, I only grade what is due each week, I will not recheck an earlier submitted section for more points. I will attach the rubric and the project template for you to use

*Make sure you follow APA in your paper. ALL APA papers must include an introduction and a conclusion. You must use headings per APA. Cite ALL your sources. Start the reference page, adding to it for each successive part. Make sure it is alphabetized. Put the reference page at the end. Follow the grading rubric for more details. If your paper is not in correct APA format you will lose points.


Part 1 (Due Week 5): 10 Points

1. Medications

Choose 5 primary medications that your patient is taking and complete the information below. Upload this table directly into your paper. The information included below should directly relate to your assigned case study client.

Drug Name Trade & generic name, dose, route & frequency

Pharmacological & therapeutic drug class &
Expected action
in the body

What medical diagnosis is your patient taking this drug for? How will it help them?

Side Effects & Adverse Reactions/ Complications/Top drug interactions

Nursing Administration Special Instructions & Assessments

Client Education Evaluation of Medication Effectiveness (e.g. Pain Scale)

1.

2.

3.

4.

5.

LABS AND DIAGNOSTIC TESTS

Choose five labs or diagnostic tests that might be ordered for your case study client. Note normal results (Rasmussen lab values), expected abnormal values, and what that would signify for your client.

Part 1 (Due Week 5): 10 Points

Topic

Points

Medication summary is complete & detailed (5 meds).

5

Laboratory and/or diagnostic tests summary is complete &

detailed (5 tests)

5

*Must include title page/reference page/citations or points will be deducted

I reserve the right to deduct any/all points if I hear a group member is not communicating/collaborating with the group. No individual papers will be accepted.


Part 2 DUE WEEK 7: 25 points

Health Assessment, Health History, and Nursing Diagnoses

In this second submission of your Course Project, you will be completing a health history, physical assessment and client interview and determining their nursing diagnoses. This written assignment should include the following:

1. Describe the medical diagnoses of your assigned client (you need to research it). Include the admitting diagnosis as number one and then four other medical diagnoses (for a total of 5). The admitting diagnosis is reason for being in the facility. If post-surgical, include surgery and reason for surgery. The secondary diagnoses include a history of pre-existing medical diagnoses). You need to include 4 secondary diagnoses. For each diagnosis, provide at least a 5-sentence explanation of the pathophysiology of the condition/problem. MAKE SURE YOU CITE YOUR SOURCES.

2. Write a detailed physical assessment and interview on your case study client. You will have to know what to expect in your client by using the information from #1 above and your case study. You will have to be creative.

3. 5 Nursing diagnoses (only the NDx, you will complete the careplan for week 10). Make sure they are in the correct format. If you give me only the label you will not get any points for nursing diagnoses.

Rubric for Part 2 (Due Week 7): 25 Points

Topic

Points

Medical history- describe the Pathophysiology of the admitting diagnosis & 4 secondary medical diagnoses (at least 5 sentences per diagnosis)

10

Head to Toe Assessment and client interview

10

Identify 5 priority NANDA nursing diagnoses written in correct format

5

*Must include title page/reference page/citations or points will be deducted

I reserve the right to deduct any/all points if I hear a group member is not communicating/collaborating with the group. No individual papers will be accepted.


Part 3 (Due Week 10): 35 points

Complete Plan of Care on your client (10 points)

In this third and final submission of your Course Project, you will be completing the comprehensive care plan. Include safety needs, special considerations regarding personal needs, cultural/spiritual implications, and needed health restoration, maintenance, and promotion.

This written assignment should include the following:

· Your Nursing diagnoses from Part 2 (use the table below)

· One short term goal and one long term goal per NDx

· Four Nursing interventions per NDx . .

· Prioritization per Maslow with an explanation and an expected evaluation. Make sure to include a teaching plan in your care plan. Upload the table below into your paper. Reflect on the following in your paper: Which of your nursing diagnoses are priority using Maslow’s Hierarchy of Needs? If you were to implement this plan of care, would you expect any of your short-term expected outcomes met during your shift? Explain. How might you revise your care plan next time to achieve at least one outcome during your shift?

Nursing Diagnoses

Use your Assessment data to ID clinical problems

Expected Outcomes (S.M.A.R.T.)

Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation)

Nursing Interventions

What can you, the nurse, do to reach the goal and improve the problem?

#1

R.T.

A.E.B.

The patient will…

Short-term goal:

Long-term goal:

The nurse will…

1.

2.

3.

4.

#2

R.T.

A.E.B.

Short-term goal:

Long-term goal:

1.

2.

3.

4.

#3

R.T.

A.E.B.

Short-term goal:

Long-term goal:

1.

2.

3.

4.

#4

R.T.

A.E.B.

Short-term goal:

Long-term goal:

1.

2.

3.

4.

#5

R.T.

A.E.B.

Short term goal

Long term goal

1.

2.

3.

4.

Part 3 – (Due Week 10): 35 pts

Topic

Points

Complete Nursing Care plan following instructions above and prioritization using Maslow and how you would evaluate the plan of care

10

Presentation to clinical group (done individually – see below)

15

APA and Mechanics (for all 3 parts)

10

If you submit your part 2 and part 3 without the previous sections, you will be penalized 50%

I reserve the right to deduct any/all points if I hear a group member is not communicating/collaborating with the group. No individual papers will be accepted.

CLINICAL PRESENTATION (Will be done your last day of clinical – Online):15 points

Clinical presentations can be based on a topic of your choosing. All topics MUST be cleared with your clinical instructor. Presentations take place on the last day of clinical. You do not need to submit your clinical presentation to the main course shell (only submit to your clinical course shell).

Choose a topic you can cover well in about 10-15 minutes. Prepare! You must be well versed in your topic as you will get questions from your peers. The presentation should include at least 3 learning objectives included in an organized, thoughtful teaching presentation outline to hand out to your audience (can either be in outline format or a PPT outline). You will need a visual (such as PPT, Kahoot!, quizzes, handouts, etc.- cannot solely include a pre-made visual such as a YouTube video).

Develop an approximate timeline to organize yourself and to assure you cover your content and answer any questions within the time allowed. Be prepared for your presentation. Presenters will be randomly chosen; Please be ready when called to avoid losing points.

Clinical Presentation Grading Rubric: Topic Must be Cleared by Clinical Instructor. Points will be added to the gradebook for your didactic.

Presentation Outline

(Includes 3 learning objectives, proper grammar & spelling, clear outline/easy to follow, visual and Reference list in APA)

5 points

Implications for Nursing (content must be related to nursing practice, include topics such as patient safety, nursing priorities, nursing interventions, etc.)

10 points

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