data collection assignment .
NURS3520: DATA COLLECTION ASSIGNMENT
STUDENT NAME: ____________________________ DATE: __________________
Instructions: Students should complete the Data Collection Assignment independently and submit as a Word document attachment on the Assignments link in Sakai by the deadline stated in the course schedule found in the syllabus. Specific grading criteria are outlined below. Do not include any patient identifiers to maintain confidentiality for the patient.
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Grading Criteria:
CONTENT
Maximum Points
Points Awarded
Comments
Data Collection (Assessment)
(44 total for this section)
Chief Complaint (signs/symptoms,
medical diagnosis)
4
Patient Demographics
4
Patient Medical History
4
Patient Surgical History
4
Significant Family History
4
Diagnostics (lab, x-ray, etc.)
4
Current Medications
4
Pathophysiology
4
Developmental Considerations
4
Nursing Considerations
4
Patient Education Needs
4
Nursing Process
(56 total for this section)
Nursing Diagnosis – high priority
according to patient presentation
and assessment data provided
.
10
Planning – Patient Goals: measurable & realistic
10
Planning – Nursing Interventions
10
Implementation (selected
intervention)
10
Evaluation
10
Format [name included, correct grammar/spelling/punctuation, include references (APA format), submitted as Word document attachment via Assignments link]
NOTE: 10 points per day will be deducted if submitted late; assignment will not be accepted if submitted more than 3 days late and assigned grade will be 0 (zero).
6
TOTAL
100
12/18/2013
Page 2 of 4
DATA COLLECTION ASSIGNMENT
CHIEF COMPLAINT
Focused assessment findings related to medical and/or
nursing diagnosis, including vital signs:
Reason for Seeking Care, History of Present Illness,
Admitting Diagnosis and/or Rationale for Transfer to
Current Level of Acuity :
PATIENT DEMOGRAPHICS
Age/Birthdate:
Gender:
Marital Status:
Race/Ethnicity:
Height/Weight:
Occupation:
Support System:
PATIENT MEDICAL HISTORY
(Childhood illnesses, accidents or injuries,
immunizations, allergies, prior diagnoses, etc.)
PATIENT SURGICAL HISTORY
(Previous hospitalizations, operations, procedures, etc.
and dates)
SIGNIFICANT FAMILY HISTORY
(Positive or negative family history of disorders
including but not limited to diabetes, hypertension,
cardiac, cancer, endocrine, psychiatric. Also include
what family member was affected.)
DIAGNOSTICS
(Include labs, x-rays, special tests, etc. related to
medical and/or nursing diagnosis and values: normal vs.
abnormal)
Page 3 of 4
DATA COLLECTION ASSIGNMENT
CURRENT MEDICATIONS (Include Dose/Route, Times-scheduled vs PRN)
PATHOPHYSIOLOGY (Include etiology & progression of disease)
DEVELOPMENTAL CONSIDERATIONS (based on developmental theory, i.e. Erik Erikson, with supporting rationale from patient data)
NURSING CONSIDERATIONS (what should the nurse take into consideration when planning/providing care)
PATIENT EDUCATION NEEDS IDENTIFIED
OTHER PERTINENT INFORMATION (such as risk factors, psychosocial risk factors; examples include smoking, limited access to care, etc.; can be left blank if no other pertinent information is identified)
Page 4 of 4
DATA COLLECTION – NURSING PROCESS COMPONENT (Refer to Ackley & Ladwig text)
NURSING DIAGNOSIS (Dx) Include one three part NANDA approved nursing diagnostic statement (include problem, etiology, symptoms). Example: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by verbal reports of weakness and abnormal blood pressure response to activity. NOTE: The diagnosis should be a high priority diagnosis for the patient. Include rationale and scholarly reference for why this is a high priority diagnosis.
PLANNING: PATIENT GOALS Identify two patient-oriented goals and include outcome criteria that are measurable and realistic. Example: The client will ambulate 25 feet by the end of the 12 hour shift.
• Goal 1: Client will:
• Goal 2: Client will:
PLANNING: NURSING INTERVENTIONS List 2 nursing interventions for each goal. Example: Monitor cardiorespiratory response to activity. The interventions should be realistic, individualized and include both rationale and scholarly reference for each.
• Goal 1 Interventions (Include two interventions for this goal): 1. Nurse will: 2. Nurse will:
• Goal 2 Interventions (Include two interventions for this goal): 1. Nurse will: 2. Nurse will:
IMPLEMENTATION Describe one intervention that was implemented. What did you do and how did the patient respond? This should be in narrative documentation format.
EVALUATION (Outcome Criteria from Planning Section Above) Describe if the outcome criteria were achieved (could be completely or partially) for both patient goals. Also identify what changes should be made in the plan and include a new target date if appropriate.
• Goal 1:
• Goal 2:
REFERENCES List all references below using APA format.
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