Module 05 Assignment – Designing a Care Map

Assessment

and

Data Collection

Three NANDA-I Approved Nursing Diagnosis

One Smart Goal for EACH Nursing Diagnosis

Two Nursing Interventions with Rationale for EACH Nursing Diagnosis

Disease Process (short description of patho of disorder- cite this- do not copy and paste):

Rheumatoid arthritis is an autoimmune process affecting synovial joints. It is chronic and systemic, causing inflammation and permanent joint damage (Ignatavicius et al., 2018)

Common Labwork/Diagnostics:

Labs:

Rheumatoid factor

ANA

ESR

Albumin (Ignatavicius et al., 2018)

Diagnostics:

Xrays

Arthrocentesis (Ignatavicius et al., 2018)

Assessment Data (consider subjective, objective, and heath history):

Subjective: joint pain, anorexia, fatigue, painful stiff joints (Ignatavicius et al., 2018)

Objective: redness in joints, deformed joints, physical limitations, decreased mobility (Ignatavicius et al., 2018)

Nursing Diagnosis: Disturbed body image r/t alteration in body function AEB painful, deformed hand joints.

Nursing Diagnosis:

Nursing Diagnosis

SMART Goal: Patient will verbalize physical changes without making disparaging comments by 5/5

SMART Goal:

SMART Goal:

1. Intervention: Provide emotional support and encourage patient

Rationale: With deformed joints, this will improve patients self -concept

(Phelps, 2021)

2. Intervention Involve patient in planning

Rationale : This will increase patient compliance with activities to the best of their ability

(Phelps, 2021)

1.
2.

1.
2.

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Assessment / Data Collection

(10 Pts)

Lacks basic factors of the disease process, common labs, diagnostic tests, and subjective, objective, and health history data.

Failure to submit Assessment/Data Collection will result in zero points for this criterion.

Briefly identifies the factors including the disease process, common labs, diagnostic tests, and subjective, objective, and health history data.

Clearly identifies the factors including the disease process, common labs, and diagnostic tests, and subjective, objective, and health history data.

Thoroughly identifies all factors including the disease process, common labs, diagnostic tests, and subjective, objective, and health history data with a deep understanding.

Points – 7

Points – 8

Points – 9

Points – 10

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

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

Interventions and Rationale

(20 Pts)

Lacks appropriate interventions and rationale to assist the client in resolving the issues leading to the problem.

Failure to submit Interventions and Rationale will result in zero points for this criterion.

Writes 3 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes more than 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Points – 16

Points – 18

Points –20

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

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.