24 Jun IDENTIFY 4 NURSING DIAGNOSIS THAT RELATE TO THE DATA COLLECTED.
Required Formal Teaching Paper:
The purpose of this required assignment is to give the student the opportunity to demonstrate the required critical thinking of ADN
252 through analysis and problem-solving skills documented in written form according to Roxbury Community College policies for
writing. The ADN 252 paper must be written using the American Psychological Association (APA) style. Students needing guidance with
preparation of the paper should meet with ADN 252 faculty member.
Student Objectives:
The student will present a patient situation, which the student has encountered during the clinical rotation that demonstrates a
teaching need. The student will develop a teaching paper that integrates the nursing process into the care needed to
identify/manage the problems presented in this patient situation.
In order to complete this assignment in a satisfactory manner, the student will (by APA guidelines):
A. Describe the patient/family situation in which patient teaching was evident based on (e.g. preparation for discharge or
understand and implement care independently)/take into account:
a. Willingness to learn.
b. Readiness and ability to learn.
i. Emotional state.
ii. Stage of adaptation to illness.
1. Emotional maturity.
2. Life experiences.
3. Goals patient and family want to reach.
c. Developmental Stage.
D. Summarize the patient/family needs/take into account:
a. Health beliefs.
b. Socio-cultural background.
c. Religious beliefs.
d. Please include: Chief complaint: What brought the client to the hospital? Use the patient’s own words, be brief. History of
present illness: This elaborates on the chief complaint. It is the “story” of what is currently happening to the client.
Incorporate any pertinent PMH. For instance, the client may have had extensive surgery for cancer and developed a wound infection
that brought him/her back to the hospital. Give a brief summary of the cancer surgery history, then record an HPI on the more
critical situation, the wound infection. Past health history, family history, social history: Is this complete? Medical? Surgical?
Allergies include drugs, foods, environmental as well as known reaction e.g. penicillin causes a rash. Review of systems: This
captures the patient’s reported complaints of each body system. This is NOT the physical assessment.
Medications: Each entry is complete? Scheduled and PRN meds? Indication is specific to assigned patient? Drug: Drug interactions
identified? Diagnostic Studies, labs.
Discuss the pathophysiology and etiology of the main medical diagnoses related to the patient situation.
30 points
C. Assessment: Subjective and Objective data that identifies the teaching need/take into account:
a. Ability to learn: physical (disabling illness) or mental deficit (severe stress)
b. Preferred learning style: Auditory (listening), Visual (seeing), Tactile (doing)
c. Pathophysiology: Give a summary of the most important medical diagnoses
10 points
D. Nursing Diagnosis: Identify 4 nursing diagnosis that relate to the data collected.
10 points
E. Planning: For each nursing diagnosis establish one goal with 1 short term and 1 long term outcome.
10 points
F. Implementation: Present the nursing interventions that could/should be used to assist/assure goal attainment. a. Teaching tools
i. Printed material
ii. Computer assisted materials
iii. Flip charts
iv. Working models
b Audios 10 points
G. Evaluation: What is actually learned/reflect on goal achievement.
a. Cognitive Domain: deals with intellectual ability.
b. Psychomotor Domain: physical or motor skills.
c. Affective Domain: expression of feelings about attitudes, interest or values.
10 points
H. Reflection: How did the patient, family and staff respond to the nursing interventions which were performed for your patient?
Discuss each specific intervention and outcome to include subjective, objective data, diagnostics, medication interventions and
evidenced based nursing actions.
15 points
I. APA Format: Is used correctly throughout the body of the paper and in the reference page.
a. Body of the paper must be a minimum of 10 typewritten pages and not exceed 17 pages. Assignment must be in APA format, typed 12
Times New Roman, double space, proper grammar. The paper must be 10 – 14 pages requirements, but all components must be thoroughly
described in the paper and must include a title and a reference page which are not part of the 10 – 14 page requirement. Tardiness
will be reflected in your grade being deducted 5 points for each day late that the paper is late (includes clinical and class
days). Paper is worth 10% of your total course grade.
b. At least 5 recent articles published within the last 5 years.
5 points
TOTAL: 100 points
Summarize
L. C. was a 76 years old female, mother of one (son), she has one brother and one sister, she is widowed, living alone but close
to her son, she is a Christian. She was admitted to BMC from the ED 2days ago following a deteriorating health status. Patient
reported 1 month of myalgias, cough with productive of white yellow sputum, gradual onset of SOB, and edema in bilateral lower
extremities despite compliance with her Lasix, difficulty of breathing. Patient stated: “I am very anxious about my health; I felt
short of breath and a sharp chest pain that getting worse when I am coughing. I felt fatigue, dizzy and I was almost fallen that is
why my son brought me to the ED” (getting a cold). Her past medical history related diagnosed in 2014 of atrial fibrillation,
Chronic kidneys disease stage III included diabetes mellitus in 2013, and hypertension and proliferative diabetic retinopathy 2009.
Her past surgery history was a cataract extraction bilateral and pan retinal photocoagulation on the left side. About her family
history: her son inherited her hypertension and diabetes mellitus; her sister has hypertension also and her brother is a cancer
survivor and she is a former smoker but never an alcohol abuser. During doctor evaluation, she was diagnosed pneumonia.
Constitutionally, positive for fever and fatigue, negative for visual disturbance, and sore throat, but positive for congestion.
Respiratory system is positive for cough and shortness of breath, cardiovascular system is positive for leg swelling and sharp
chest pain. Gastrointestinal system negative for abdominal pain, diarrhea, nausea and vomiting. Genitourinary system is negative
for dysuria, musculoskeletal system is positive for myalgias, but negative for back pain and neck stiffness. Skin negative for
rash, neurological system negative for headache, however the patient’s son reported some occasional confusion at the behavioral
level.
common symptom of the disease is cough which is followed by fatigue. Other common symptoms include fever, SOB and rusty or bloody
sputum. However, many of its symptoms are similar to many other respiratory diseases. The only way to confirm this diagnosis from
another is clinical tests.
Subjective data: Patient reported 1 month of myalgias, cough with productive of white yellow sputum, and edema in bilateral lower
extremities despite compliance with her Lasix, difficulty of breathing. Patient stated: “I am very anxious about my health; I felt
short of breath and a sharp chest pain that getting worse when I am coughing. I felt fatigue, dizzy and I was almost fallen that is
why my son brought me to the ED” (getting a cold). Patient’s son reported reduced mom’s LOC
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