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Question Course Project Milestone #2: Nursin

Question Course Project Milestone #2: Nursin

Question
Course Project Milestone #2: Nursing Diagnosis and Plan of Care Form

Your Name: Date:

Your Instructor’s Name:

Directions: Refer to the Milestone 2: Guidelines found in Doc Sharing to complete the information below. This assignment is worth 300 points.

Type your answers on this form. Click “Save as” and save the file with the assignment name and your last name, e.g., “NR305_Milestone2_Form_Smith”. When you are finished, submit the form to the Milestone 2 Dropbox by the deadline indicated in your guidelines. Post questions in the Q & A Forum or contact your instructor if you have questions about this assignment.

1: Analyze Assessment Data:

Based on the health history information, identify the following:

A. Areas for focused assessment (15 points)

Provide abriefoverview of those areas of strength and weakness noted from Milestone 1: Health History.

B. Client’s strengths (30 points)

Expand on areas identified as strengths related to the person’s overall health. Support your conclusions with data from the textbook.

C. Areas of concern (30 points)

Expand on areas previously identified as abnormal and those that place the person at a health risk. Support your observations with data from the textbook.

D. Health teaching topics (20 points)

Identify health education needs. Support your statements with facts from the Health History and information from your textbook.

2: Physical Examination Assessment

A. Vital signs (15 points)

B/P_________P_________R_________

Please document quality, characteristics, rate and depth:

B. Respiratory examination (30 points)

Ask relevant respiratory history and Review of Systems questions

History of Croup or Asthma? Y_________N_________

History of wheezing? Y_________N_________

Noisy breathing? Y_________N_________

Shortness of breath Y_________N_________

Chronic cough? Y_________N_________

Exposure to cigarette smoke of Environmental/Noxious fumes? Y_________N_________

If yes, explain_________

Most recent TB testing _________

Last Chest X Ray_________

Auscultate all lobes for lung sounds and document below.

RUL: __________

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