Section Description of Full Points Possible Points Points Earned Patient introduction • Full sentences • Grammatically correct • Only acceptable abbreviations Includes, in order: No initials, please refer to 'Patient' as identifier • Age, gender, race: (State age as: <65 years, 65-74, 75-84, 85-95, >95 years) • Reason for admission • History of present illness • Past medical/surgical history summary (If unknown, state what questions you would ask) • Allergies • Code status (If unknown, state what you would expect based on the client's condition) 6 Assessment and interpretation • Focused assessment complete and accurate (pertinent to the objectives of case) • Problems identified are in keeping with the data recorded and are stated as a NANDA Diagnosis • Section identifying areas you would like to assess but were unable to do so. 10 DocuCare Documentation • DocuCare assessment submission is complete, on time, and accurate. • Assessment and interventions documented correlates with care provided. 2 Diagnostic data • Lab and radiology data results are correctly interpreted in light of the patient's history and current condition. • Normal and abnormal interpretation of lab and radiology data is interpreted and discussed for significance to patient status and disease pathology. • If lab/diagnostic data is unavailable, discuss what would be warranted or recommended with appropriate cited rationale 8 Pathophysiology flowchart Pathophysiology flowchart - Pathophysiology of the most relevant disease process must be described (not defined) • At least 4 pathophysiologic factors affecting this patient's condition needs to be described • Illustrates interrelationships among the factors (i.e., cause, effect, increases, decreases, predisposes, protects, etc.) 7 Morbidity and mortality • Full sentences • Grammatically correct • Only acceptable abbreviations Morbidity and mortality statistics are given for the pathophysiological disease process discussed in flowchart incidence and/or prevalence • risk factors • population groups affected • resulting morbidity and mortality 4 Medications • Medication list correctly identifies the mechanism for action, drug classification, patient's dosage, and purpose of each medication specific to this particular patient • If your patient is not ordered any medications: Suggest at least 4 medications that you might request the provider order for this patient in light of their condition and list the MOA, drug classification, suggested dose, and potential purpose/ your rationale for recommending specific to this patient 8 Diagnosis Two physical and 2 psychosocial diagnoses are identified 5 Diagnoses are in keeping with assessment data recorded within paper 5 Diagnoses are high priority and amenable to nursing intervention 5 Diagnoses use NANDA labels and are correctly expressed (i.e., include etiology and/or defining characteristics as appropriate – PES as discussed in lecture problem, etiology and sign/symptoms) 5 Plan A plan is written for one physical and one psychosocial diagnosis 5 Outcome or goals Outcome statements • address the diagnosis • are realistic and patient specific • are measurable, observable and stated with appropriate time frame • Must have at least 1 long term goal and 3 short goals for each problem identified 5 Implementation (Intervention) Interventions are • appropriate to address the diagnosis • safe, patient specific and appropriate • some are original or innovative (need to be stated with own rationale) • Rationales are given for each intervention and are appropriately cited via APA format 10 Interventions take into account this patient's unique strengths, resources, and/or preferences 5 Evaluation A statement as to whether goals were met or not met is made for each outcome; if met quantify or qualify the degree to which the outcome was achieved. 5 APA Format • Spelling • Grammar • Punctuation Clarity of writing are all a part of APA style Must have at least three references- (unless a seminal paper, none older than 5 years). References must be properly cited using APA format. At least one reference must be an article that is addressed within interventions. https://owl.english.purdue.edu/owl/resource/560/01/ 5 TOTAL Points 100 Comments: *Follow exactly what is on the Care Plan Grading Rubric. Section by section, line by line. Patient Introduction o Remember to avoid identifiers to maintain patient confidentiality: No initials, no birthdate, decade for age, do not give name of facility or hospital. Stage age in designated range as listed on the rubric. o Write in paragraph narrative format, following APA format, and complete sentences. o Include every section in the rubric. Patient Introduction (Specific Example) Patient is (give age group 66-74, 75-85, >85 years) Caucasian female. Patient was admitted to the skilled nursing facility on 9/21/12 after suffering an acute CVA the day after she had surgery for a hip fracture to her right femoral neck which was required due to a fall at home. Patient suffers from mild expressive aphasia as a result of the CVA. Her memory of the events surrounding the fall are not clear. She states that she was not with anyone at the time of the fall and she does not remember if she blacked out or lost consciousness. She states that someone found her in her apartment and she was taken to Hospital where she said she had a "rod" put in her hip. Patient has a past surgical history of hemiarthroplasty for her right femoral neck fracture, back surgery, lumpectomy for breast cancer, and tonsillectomy. She also has a past history of HTN, DM, high cholesterol and glaucoma. Patient's father and mother died of natural causes. Some diabetes in the family. Patient has lived in the DC area all her life. She attended college and graduate school and states that she got a degree in food service management and she "fully enjoyed" that. She was never married and does not have any children. However, she states that she has many friends who she sees and visits with often. She enjoys visiting with all her friends and spending time with people. She expects to be able to return home to her apartment at an assisted living facility within the next week. She says that she has a lot of friends who will help her. She also has a cousin who is a surgeon who has been helping with everything. Patient does not have any known allergies. Code: Attempt CPR Last updated: Fall 2020 Assessment and Interpretation *Physical Assessment: Use your textbook! Problems identified are stated as NANDA Diagnosis and follow the assessment. Include all body systems. Example: Assessment: 10/26/2025 and 11/2/2025 Problems: G-U: 10/26/25 Patient denies problems with urination. Patient states that she urinates 4-5 times a day and states that her urine appears "clear with nothing abnormal". When asked about fluid intake, patient states that she should "probably drink more water" and she then proceeded to drink some of her water at her bedside. When the patient showed me the scar on her right hip from her hip surgery, I noticed she also was wearing depends. I should have asked her if she had any problems with incontinence after noticing the depends. -Risk for deficient fluid volume r/t decreased intake AEB patient's report that she should "probably drink more water" (Doenges, Moorhouse, & Murr, 2010, p. 379-380). DocuCare Documentation: Ensure that you patient documentation is complete, accurate, and submitted for instructor review. Document your assessment and any interventions conducted. *Individualize each lab result to the specific patient. For example: Labs, why is it normal or why would it be high/low according to the patient's history and current condition. The patient has low hemoglobin and hematocrit because they are anemic. This is the same for meds. Ask yourself "Why is this patient taking this medication?" The patient is taking Norvasc because they have a history of high blood pressure. *You may make charts for labs and meds. For Labs, split, normal range, patient's result, and significance. For medications, split medication, dose/route/frequency, drug class and Mechanism of Action (MOA,) indication for YOUR patient. Don't forget to cite your lab and medication chart (ie: where did you find the information for normal values, drug class, MOA, and significance). Examples Lab Normal Value* Patient's Result Significance* RBC 3.90 – 5.40mil/uL 3.46 Low Expected finding based on patient's diagnosis of anemia *Citation for lab table Last updated: Fall 2020 Medication Generic and Trade Name Drug Classification and MOA* Patients Dose/Route/Frequency Indication (Purpose specific to this patient)* Calcium Carbonate and Cholecalciferol (Caltrate Plus D) Calcium supplement and vitamin D Hormone. MOA: Essential component and participant in physiologic systems and reactions. Calcium Carbonate 600mg Cholecalciferol 400mg 1 tab PO daily Calcium for low levels of calcium in the blood and Vitamin D to prevent muscle pain with statins. *Citation for Medication table Other Diagnostic Tests Results Significance* Chest X-ray (12/25/2025) No evidence of active cardiopulmonary disease. Reveals peripheral lung fields are clear of lobar infiltrates and effusions. Cardiac silhouette and pulmonary vascularity are normal. Expected finding based on patient history of no lung or cardiac problems. Patient IntroductionLocation: Orthopedic unit 0800SBAR report from a night nurse:Situation: Jared Griffin is a 63-year-old African American male who had a right total knee arthroplasty (TKA) yesterday morning. Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension.Assessment: Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2-3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees. The surgeon changed Mr. Griffin's dressing, and discontinued the drain and IV fluids, at 0700 on his morning round. His labs just came up, but I haven't had a chance to look at them yet.Recommendation: You'll need to go in and do your morning assessment. Continue with contact precautions, and observe for signs and symptoms of infection.Fundamentals of Nursing CareTPatient IntroductionLocation: Orthopedic unit 0800SBAR report from a night nurse:Situation: Jared Griffin is a 63-year-old African American male who had a right total knee arthroplasty (TKA) yesterday morning. Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension. Assessment: Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2-3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees. The surgeon changed Mr. Griffin's dressing, and discontinued the drain and IV fluids, at 0700 on his morning round. His labs just came up, but I haven't had a chance to look at them yet. Recommendation: You'll need to go in and do your morning assessment. Continue with contact precautions, and observe for signs and symptoms of infection. Fundamentals of Nursing CareT

ANSWER. PAPER DETAILS
Academic Level	Undergraduate
Subject Area	Nursing
Paper Type	Assignment
Number of Pages	15 Page(s)/4125 words
Sources	3
Format	APA
Spacing	Double Spacing

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