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Assignment 3: Case Study Analysis and Care Plan Creation

Click here(which I have attached) to download and analyze the case study for this week. Create a holistic care plan for disease prevention, health promotion, and acute care of the patient in the clinical case. Your care plan should be based on current evidence and nursing standards of care.

Visit the South University Online Library and research for current scholarly evidence (no older than 5 years) to support your nursing actions. In addition, consider visiting government sites such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Agency for Healthcare Research and Quality (AHRQ), and Healthy People 2020. Provide a detailed scientific rationale justifying the inclusion of this evidence in your plan.

Next determine the ICD-10 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.

Click here to access the codes.(which I have attached)

You are expected to develop a comprehensive care plan based on your assessment, diagnosis, and advanced nursing interventions. Reflect on what you have learned about care plans through independent research and peer discussions, and incorporate the knowledge that you have gained into your patient’s care plan.

Format

Click here to download the care plan template to help you design a holistic patient care plan.

Your care plan should be formatted as a Microsoft Word document. Follow APA style. Your paper should be 2 pages not including the title page and references and in 12pt font.

Assignment 3 Grading Criteria

Maximum Points

Subjective Data

The submission described the patient’s interpretation of current medical problem and included chief complaint, history of present illness, current medications and reason prescribed, past medical history, family history, and review of systems.

15

Objective Data

The submission included the measurements and observations obtained by the nurse practitioner, including head to toe physical examination as well as laboratory and diagnostic testing results and interpretation (especially those that pertain to the diagnosis).

15

Assessment

The submission included at least three priority diagnoses. Each diagnosis was supported by documentation in subjective and objective notes and free of essential omissions. All diagnoses were documented using acceptable terminologies and current ICD-10 codes.

15

Plan of Care

Plan included diagnostic and therapeutic (pharmacologic and non-pharmacologic) management as well as education and counseling provided. The plan was supported by evidence/guidelines, and the follow-up plans were noted.

20

APA

The submission used APA standards consistently and accurately when citing in the SOAP note and reference page. Utilized proper format with coversheet and header.

10

Total

75

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