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Example of how the assignment should look like is attached.
Instructions:
Assessment and Medical History • Evaluation of the assessment and medical history is the basis for planning care. • Is complete and accurate, containing pertinent subjective and objective data related to the patient’s problem and nursing diagnosis. Nursing Diagnosis: The Nursing Diagnosis included all 3 components of: • The three (3) nursing diagnosis (NANDA approved) • A diagnosis that correlates with the assessment data • The “Related to” correlates with patient’s data collected in the assessment and is not a medical diagnosis. • The “As evidenced by” correlates with the assessment data documented on the assessment form (only if actual diagnosis) Planning: The Planning included all 28-30 components of: 3 short-term goals • Related to the nursing diagnosis • Patient-centered • Realistic for patient situation • Includes a time frame • Is measurable 3 long-term goals • Related to the nursing diagnosis • Patient-centered • Realistic for patient situation • Includes a time frame • Is measurable Interventions: Nursing Interventions assist the client in meeting short-term and long-term goals. The interventions section should include a minimum of 3 nursing interventions for each of the three nursing diagnosis. included all 6 components of: • Minimum of 3 nursing interventions for each nursing diagnoses. Each intervention should: • Contribute to the achievement of goals • Be comprehensive (include specific action, frequency, healthcare member to perform, etc.) • Be appropriate for the patient’s situation • Have a scientific rationale • References cited in APA format Evaluation: This criterion is linked to a Learning outcome evaluation of goals to make decisions and recommendations for continued patient care. The Evaluation included all 6 components of: Each short-term and long-term goal evaluated to determine • If goals were met, partially met, or not met. • Must be patient and/or family-centered • Must provide evidence Development: The development of the diagram incorporates clinical judgement and critical thinking of patient care. The clinical impression of data is easily identified; sub concept problems are prioritized and branch appropriately. The development of the diagram is linked logically from the main idea. Linking Data: Linking the data shows a connection between the nursing and medical diagnosis and care based on data. The data is linked and interrelated between the nursing and medical diagnosis and the concepts related showing a holistic mindfulness. Definition: Explain what “Type 2 Diabetes is”.
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