Use the steps in the nursing process to complete a thorough initial assessment, identify pertinent nursing diagnoses and develop a client specific plan of care.

Care Plan Assignment: Instructions

Directions:

Use the steps in the nursing process to complete a thorough initial assessment, identify pertinent nursing diagnoses and develop a client specific plan of care.

Step 1: Assessment-

Using the NSG100 Initial Client Assessment Form or one specific to your clinical setting; complete a comprehensive health history and physical exam on your client.

Step 2:

Nursing Diagnosis/planning-

After reviewing and validating the client’s initial assessment data, the next step is to form diagnostic conclusions. Using the NANDA-I format list all actual and potential health problems for your client in the table provided at the end of the assessment form.

After you have identified the clients nursing diagnosis and collaborative problems, prioritize/rank your diagnosis in order of importance (High, Medium, Low)

Components of a Nursing Diagnosis include:

Diagnostic Label: The name of the nursing diagnosis within the NANDA-I taxonomy
Related Factor: A condition or etiologic factor which may be modified by nursing intervention

Defining Characteristics (“as evidenced by”): symptoms/data that the nurse has identified in the assessment.

NOTE:

Risk Diagnoses do not have defining characteristics but are supported by assessed risk factors.
Step 3-5: Planning, Implementation& Evaluation- Using the care plan template provided, complete the client plan of care for two nursing diagnosis identified as

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