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NSG125FullCarePlanRevised11.17.23.docx

Instructions:

During the NSG125 Transition to Professional Nursing course, students will complete a total of one care plan assignment as follows:

1. Care Plan based on a simulated client case from Shadow Health – OR

2. Care Plan based on a clinical site client.

Care Plan Map Components:

· Part I: Physical Assessment

· Part II: History & Physical

· Part III: Medications

· Part IV: Diagnostic Studies & Interpretation/Assessment Explanation

· Part V: Clinical Judgement Measurement Model Table

Rubric: Must achieve 16 points to pass clinical.

1. Care Plan based on a simulated client case- OR a Care Plan based on a clinical site client

Criteria	4 points	3 points	2 points	0 points	Total Points
Part I: Physical Assessment	All components of the physical assessment are present.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the assessment areas are lacking information.	Assessment information not provided
Part II: History & Physical	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part III: Medications	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part IV: Diagnostic Studies & Interpretation/Assessment Explanation	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Part V: Clinical Judgement Measurement Model Table	Information is complete and accurate; All areas of the section are addressed.	Most of the information is provided with all areas addressed. No more than 3 missing areas.	No more than 6 of the history & physical areas are lacking information.	Assessment information not provided
Total points	/20

Part I: Physical Assessment

VS Time: Temperature Pulse Respirations BP / Pain /10

GENERAL SURVEY
	Age___________ Male/Female/Other Body Build: WNL Muscular Obese Thin Cachectic Height___________ Weight____________ Well-groomed Poorly Groomed Facial Expression: Content Happy Anxious Sad Angry Flat
NEUROLOGICAL
(LOC) Level of Consciousness	Alert Awake Lethargic Obtunded Stupor Comatose Confused Oriented x 4: If not alert X 4, circle what they are alert to: Person Place Time Situation
Eyes	Unaided sight Glasses Contact lens Blind
Pupils	Equal Round Reactive to light Accommodates List abnormal findings:________________________________________ Pupil reaction: Brisk Sluggish Nonreactive to light Pupil size: before light ______mm after light ______mm
Ears	Unaided hearing Hard of hearing Deaf Hearing aid Implant
Extremity Strength	Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
Pain	Location: Onset (when did it start): Provokes (makes it worse): Palliates (makes it better): Quality (description): Radiate: location: Severity: ___/10 Time: Constant Intermittent
CARDIOVASCULAR
Skin / Mucous Membranes	Normal for Ethnicity Pallor Cyanotic Jaundiced Ruddy Flushed Diaphoretic
Radial and Pedal Pulses	Radial: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent Pedal: Right: Strong Weak Thready Absent Left: Strong Weak Thready Absent
Apical Radial Pulses	(2 assessed simultaneously) Equal Pulse Deficit
Capillary Refill	Normal (<3 Sec) ______sec Location:________________
Edema	Absent Present: location +1 +2 +3 +4 Non-Pitting
Heart Rhythm/ Sounds – S1S2	Heart Rhythm: Regular Irregular Heart Sounds: S1/S2 Murmur Extra Sounds Sound: Strong Distant
IV	None Solution_______________ Rate ____ml/hr Site location (be specific) ______________________________________ Site appearance: WNL Edema Erythema Tender Pallor Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________
RESPIRATORY
Respirations	Pattern: Regular Irregular Effort: Unlabored Labored Nasal flaring Sternal retraction Intercostal retraction Chest Expansion: Symmetrical Asymmetrical
Lung Sounds	Anterior : Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______ Posterior: Clear______ Wheezes______ Crackles ______ Rales______ Rhonchi______ Diminished______
Cough	None Non-productive Productive Sputum: amount color
Oxygen	Room air O2 at_____L/min Nasal Cannula Oximizer Simple Mask Partial Re-Breather Mask Non-Rebreather Mask
Respiratory Treatments	Incentive Spirometer (IS): ml______ # of times______ Nebulizer:_____________ Inhalers:______________ Flutter Valve:_______________
GASTROINTESTINAL
Oral	Mouth: Teeth Dentures Caries Swallowing: Gag reflex Dysphagia Mucous Membranes: intact moist dry pale pink
Abdomen:	Contour: Soft Round Flat Scaphoid Obese Palpation: Firm Hard Tender Non-Tender Location: Distention: Nondistended Distended
Bowel Sounds	RLQ Normoactive Hypoactive Hyperactive Absent RUQ Normoactive Hypoactive Hyperactive Absent LUQ Normoactive Hypoactive Hyperactive Absent LLQ Normoactive Hypoactive Hyperactive Absent
NG/ GT/ JT	None Type of tube _____ patent non-patent Purpose: Suction Feeding Medication Administration Type of food: _________ Fluid Flush__________mL
Bowel Movement	Continent Incontinent Last BM__________ Color Consistency Ostomy: yes no
Nutrition	Self-feed Needs assistance Diet___________ % eaten Breakfast_______ Lunch________ NPO_________ if yes, why?___________ Thickened liquids: honey nectar pudding Food Consistency: Regular Mechanical Soft Pureed Tube Feed: Yes or No
GENITOURINARY
Urine	Continent Incontinent Urgency Hesitancy Frequency Burning Nocturia Catheter type _______________ None Color_________________ Clear Cloudy Sediment Burning Frequency
Intake and Output	PO/Oral/Tube Feed intake____________ mL IV intake____________ mL Urine output_________ mL Other output_________ mL Fluid restriction ___________mL/day
MUSCULOSKELETAL
ROM	Active ROM: Completed____________ Passive ROM: Completed____________
Mobility	Ambulatory assistance: Independent Gait belt Cane Walker Crutches Wheelchair Walks: distance frequency tolerance PT OT
Other Musculoskeletal	Cast: Location: Brace: Type: Location: Amputation: Location:
Risk for Falls	Bed alarm Chair alarm 1 or 2 Person Transfer Floor mat Side Rails Mechanical Lift Slide Board
INTEGUMENTARY
Appearance	Color: Normal for Ethnicity Pallor Rash Bruise Lesions Intact OR Non-Intact: Location of Non-Intact Areas_____________________________________________________ New Scars: Location _________________________ Dressing change: (describe: location, steps, drainage, wound)
Temperature and Moisture	Temperature: Warm Hot Cool Cold Moisture: Dry Moist
Incisions/Wound	None Surgical site – Location Incision Edges: Well-approximated Sutures Staples Steri-strips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________ Wounds Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough Location: Wound appearance Tunneling Eschar Slough
PSYCHOSOCIAL
Behavior	Cooperative Uncooperative Pleasant Withdrawn Combative Other_______________
Language spoken	English = speaks and understands other_________________ Interpreter

Part II: History and Physical
Nursing Care Plan:	Date:
A. Client identifiers: Physician (s): Age: Gender: Ht: Wt. Code Status: Isolation Status:
Health States
Date of admission: Activity level: Diet: Fall risk: Client’s chief complaint: Client’s past medical and surgical history Allergies:	Mobility needs: (Independent, partially-dependent, full-assist) Interdisciplinary Consults (PT/OT/RT/ST/other): Referrals to Specialists (pulmonary, cardiac, neuro, etc.)
Socio-cultural Orientation
Cultural and Ethnic Background Social history (include alcohol, drugs, smoking, suicidal ideation, risk for violence/physical, and financial abuse) Barriers to independent living

Part III. Medications
List medications, dosages, classifications, and the rationale for the medications prescribed for this client, including major considerations for administration and the possible negative outcomes associated with this medication. A maximum of twelve (12) medications focus on the medication corresponding to the patient’s primary and chronic health conditions.
ALLERGIES:
Medication, Classification, Mechanism of Action	Dosage/Route	Contraindications, Adverse Reactions/Side Effects, Risk Factors,	Client Education and Nursing Implications	Why is this client getting this medication?

PART IV: Diagnostic studies and Interpretation (Maximum of 5 lab values)
Labs	Normal Values	Results	What do these results indicate?	Identify 2 interventions based on the laboratory findings (examples: Medications, procedures, positioning)

Assessment Explanation
Identify three (3) nursing interventions based on the Physical Assessment findings	1.
	2.
	3.
State the educational needs of this client.	1.
	2.
	3.

NSG125 Transition to Professional Nursing- Care Plan

9 Revised:11/17/2023

PART V: Clinical Judgement Measurement Model Table

Recognize Cues

Identify five (5) abnormal Signs, symptoms, risk factors, labs, and health history, clinical manifestations.

Prioritize

Using the Recognize Cues column to prioritize the chief complaints

Generate Solutions

List three (3) nursing interventions needed for this client. Use the three (3) interventions identified above.

Evaluate Outcomes

How would you determine the effectiveness of your nursing interventions?

MN664

his week’s reflective journal assignment will allow you to investigate areas for clinical preparation in psychiatric mental health. The reflective journal should abide by APA writing standards, include a minimum of one reference in APA format, and be a minimum of 250 words.

Review the Mnemonics in Psychiatric Mental Health Care article:

Caplan, J. P., MD., & Stern, T. A., MD. (n.d.). Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis (Links to an external site.). Current Psychiatry, 7(10), 27-33. http://mcmasterpa.weebly.com/uploads/1/2/7/3/12737575/0710cp_article2.pdf

Write a brief summary of how you will utilize these menuemonic tools in practice. Are there any others you have used in your nursing career in the past that you still recall? What other tips are helpful to you in clinical practice to retain information?

Tip: Choose one to memorize and implement it into practice each week for the remainder of the term. Create a memory notecard with the mnemonic information on one side and the NAME on the other to help you recall them.

Example: DIGFAST; Distractibility, Indiscretions, Grandiosity, Flight of Ideas, Activity Increase, Sleep deficits, Talkative

To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of the Course Resources.

Submit your assignment to the unit Dropbox before midnight on the last day of the unit.

Draft a 3–5 page change proposal to executive leaders, soliciting their support for a change to the health care system in the community you selected in the previous assessment.

To improve health care outcomes within a community, leaders must understand the needs of specific populations. In addition, it is important that leaders are able to gather and present persuasive evidence to decision makers to obtain the necessary funding and establish these needs as priorities for budget and resource planning. Thus, proposed changes should support improved outcomes and align with the current or needed health care policy.

This assessment provides an opportunity to propose a community health care change that is based on the community health assessment you completed in Assessment 2.

Your community health assessment was well received by the executives at Vila Health. Consequently, they have asked you to recommend a change in the community that will improve health outcomes. They have also asked you to submit your recommendation in a formal change proposal. You are confident that you can present a strong case for change, including a financial plan, that will ensure the success of this initiative.

In this assessment, you will draft a change proposal to executive leaders to solicit support for a change to the current community health care system. To prepare for the assessment, you are encouraged to begin thinking about your justification for establishing the recommended change as a priority, a strategy for leading change, and how the change will be funded. In addition, you may wish to:

Review the assessment requirements and scoring guide to ensure that you understand the work you will be asked to complete.
Review Guiding Questions: Planning for Community and Organizational Change [DOCX] Download Guiding Questions: Planning for Community and Organizational Change [DOCX], which includes questions to consider and additional guidance on how to successfully complete the assessment.

Note: As you revise your writing, check out the resources listed on the Writing Center’s Writing Support page.

The following resource is required to complete the assessment.

Vila Health: Planning for Change.

Vila Health is a virtual environment that simulates a real-world health care system. In the various Vila Health scenarios, you will apply professional strategies, practice skills, and build competencies that you can apply to your coursework and in your career. The information you gather in this scenario will help you to complete the assessment.

Complete this assessment in two steps:

If you have not already done so, complete the Vila Health: Planning for Change simulation.
Draft a change proposal to justify your recommendation for improving the health of the community and establish the change as a priority for the next budget cycle. Consider the feasibility of your proposed change, in terms of overall scope, funding, and timeframe.

The change proposal requirements outlined below, correspond to the grading criteria in the scoring guide, so be sure to address each point. Read the performance-level descriptions for each criterion to see how your work will be assessed. The Guiding Questions: Planning for Community and Organizational Change document provides additional considerations that may be helpful in completing your assessment. In addition, be sure to note the requirements below for document format and length and for citing supporting evidence.

Identify the benefits of proposed health care system changes and its implications for a community.
Describe potential barriers to change in an organization or community.
Develop strategies for changing barriers into opportunities and resolving conflict.
Develop a strategy for helping organizational stakeholders understand and evaluate the proposed changes to an existing health care system.
Develop a grant proposal and associated budget for a proposed change to an existing health care system.
Write clearly and concisely in a logically coherent and appropriate form and style.
Support assertions, arguments, propositions, and conclusions with relevant and credible evidence.

cf_change_proposal_template1.docx

CHANGE PROPOSAL 7

CHANGE PROPOSAL 8

Change Proposal

Your Full Name (no credentials)

School of Nursing and Health Sciences, Capella University

NURS-FPX6218 Leading the Future of Health Care

Planning for Community and Organizational Change

Instructor’s Name

Month, Year

Title of Paper

Note: Delete this note and all instructions from the template before submitting your proposal. Use headings to organize your text, rather than bullets.

Summary

Benefits and Implications

Identify the benefits of proposed health care system changes and its implications for a community.

Consider the goals and potential outcomes of the proposed changes.

What are the direct benefits of your proposed changes?

How will improvements in overall health affect the community?

Potential Barriers to Change

Describe potential barriers to change in an organization or community.

What factors in an organization and community create or contribute to resistance to changes?

What other factors can create barriers to change?

Articulate strategies for changing barriers into opportunities and resolving conflict.

What are the drivers of change in organizations and communities?

How will you communicate with stakeholders and overcome resistance?

How will you resolve conflict among competing interests?

Stakeholder Communications

Articulate a strategy for helping organizational stakeholders understand and evaluate proposed changes to the existing health care system.

Who are the key stakeholders in the organization?

What influence do they have on your proposal?

Consider the effects of these changes on the organization and the specific information needs of decision makers.

References

List your APA-formatted references here.

Appendix A: Grant Proposal

Need Statement

Define the problem that this change is addressing.

Describe the scope of the problem.

· Who is affected? How will you describe this population?

· How many people does this problem affect?

Identify the barriers you are likely to encounter when implementing this change?

Identify the sources of information you used to define the need for change.

Identify any other change initiatives or studies that are addressing this problem.

Program Description

Describe the proposed change initiative and how you plan to implement it. Address the basic questions of who, what, when, where, why, and how.

Goals and Objectives

Describe the goals and objectives of the change initiative.

Program Evaluation

Explain how this change initiative will be evaluated.

· Who will have oversight responsibilities?

· How and how often, will this initiative be evaluated?

· Who is the recipient of the evaluation reports?

· What is the extent of stakeholder involvement in evaluation?

Summary

Explain why this change is important to the community.

Explain how the goals and objectives of this change initiative align with those of the funding organization and why their financial support is vital to the success of this initiative.

Be sure to thank the funding agency for considering and supporting this initiative.

Appendix B: Project Budget

Table directions:

Add table rows, as needed, for each budget category.

Enter the information (startup, first-year budget figures, other sources of revenue, and justification) for each budget category line item in columns 2–5.

Categories	Startup	1st Year	Other Sources of Revenue	Justification
Salary and Wages
· Project Manager
· Support Staff
· Other
·
·
Fringe Benefits
·
·
·
Consultation or Contract Services
·
·
·
Equipment
·
·
·
Materials
·
·
·
Travel
·
·
·
Miscellaneous or Other
·
·
·
Total Expenses

Healthcare Quality and Safety Management 4

As a nurse leader, you will be expected to communicate effectively with leaders and stakeholders at all levels in an organization in a variety of ways, depending on your purpose and your audience. Being able to deliver effective presentations is one important skill you will likely be called upon to use often.

Healthcare Quality and Safety Management 1

As a nurse leader, you must be able to assess your organization's ability to deliver safe, high-quality patient care. In so doing, you may be required to perform a gap analysis of a quality or safety issue as the first step in improving outcomes. Failure to meet benchmarks for safe and effective patient care can have reimbursement, regulatory, and legal consequences.

Healthcare Quality and Safety Management 2

As a nurse leader, you must be able to access, identify, and describe outcome measures as they relate to safety and quality problems in your organization.

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PLEASE DONT BID IF YOU CANNOT HANDLE THIS WORK. INSTRUCTION IS ATTACHED

MN664

Draft a 3–5 page change proposal to executive leaders, soliciting their support for a change to the health care system in the community you selected in the previous assessment.

Change Proposal

Your Full Name (no credentials)

NURS-FPX6218 Leading the Future of Health Care

Planning for Community and Organizational Change

Month, Year

Title of Paper

Summary

Benefits and Implications

Potential Barriers to Change

Stakeholder Communications

References

Appendix A: Grant Proposal

Need Statement

Program Description

Goals and Objectives

Program Evaluation

Summary

Appendix B: Project Budget

Healthcare Quality and Safety Management 4

Healthcare Quality and Safety Management 1

Healthcare Quality and Safety Management 2

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