NUR 2356 Browling Green State University Mod 9 Impaired Immune System Paper

Module 09 Assignment – Impaired Immune SystemCare Map
System Care Map
Purpose of Assignment
For this assignment, you will demonstrate knowledge of the diagnostic process using the template below. You will identify
common assessment data, three priority nursing diagnoses, client-centered outcomes, and nursing interventions with rationale
for a client with impaired immunity.
Course Competency
•
Describe strategies for safe effective multidimensional nursing practice when providing care for clients experiencing
immunologic, infectious and inflammatory disorders.
Instructions
Tom Howard, a 45-year old man with HIV from the community, has come to the clinic because he reports he had not been
feeling well recently. During the intake process, Tom complains of a dry cough and chilling. The intake nurse takes his vital
signs, and they are: Temp 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure 135/86.
The clinic physician refers Tom to the local hospital for a suspected opportunistic infection.
Suspected opportunistic infections for this patient are: (choose ONE to complete this template)
•
•
•
•
•
Cryptococcosis
Cytomegalovirus
Histoplasmosis
Kaposi’s sarcoma
Toxoplasmosis
Use the template directly below these instructions to complete a care map to design care for a client with impaired immunity.
For this assignment, include the following: assessment and data collection (including disease process, common
labwork/diagnostics, subjective, objective, and health history data), three NANDA-I approved nursing diagnosis, one SMART
goal for each nursing diagnosis, and two nursing interventions with rationale for each SMART goal for a client with a immune
system disorder.
Use at least two scholarly sources to support your care map. Be sure to cite your sources in-text and on a reference page using
APA format.
Check out the following link for information about writing SMART goals and to see examples:
http://rasmussen.libanswers.com/faq/212524
You can find useful reference materials for this assignment in the School of Nursing guide:
https://guides.rasmussen.edu/nursing/referenceebooks
Have questions about APA? Visit the online APA guide:
https://guides.rasmussen.edu/apa
Assessment
and
Data Collection
Three NANDA-I Approved
Nursing Diagnosis
One Smart Goal for EACH
Nursing Diagnosis
*Risk: Nursing
diagnosis____Related to_____
*Specific and measurable with
a timeline. Find from the
nursing diagnosis book (under
client or expected outcomes
section) and individualize to
your patient-ONE SENTENCE
*Actual: Nursing
diagnosis____Related to____ as
evidenced by
3 Nursing Interventions
with Rationale for EACH
Nursing Diagnosis
Disease Process: (short
description of patho of
disorder- cite this):
Nursing Diagnosis:
SMART Goal:
1.
Rationale:
2.
Rationale:
3.
Rationale:
Cite:
Common
Labwork/Diagnostics:
Nursing Diagnosis:
SMART Goal:
1.
Rationale:
2.
Rationale:
3.
Rationale:
Cite:
Nursing Diagnosis
SMART Goal:
Assessment Data (consider
subjective, objective, and
heath history):
1.
Rationale:
2.
Rationale:
3.
Rationale:
Cite:
Module 09 Assignment – Impaired Immune System Care Map Rubric
Total Assessment Points – 65
Levels of Achievement
Emerging
Competence
Proficiency
Mastery
Lacks basic factors of the
disease process, common labs,
diagnostic tests, and subjective,
objective, and health history
data.
Failure to submit
Assessment/Data Collection will
result in zero points for this
criterion.
Points – 7
Briefly identifies the factors including
the disease process, common labs,
diagnostic tests, and subjective,
objective, and health history data.
Clearly identifies the
factors including the
disease process,
common labs, and
diagnostic tests, and
subjective, objective,
and health history data.
Thoroughly identifies all
factors including the
disease process, common
labs, diagnostic tests, and
subjective, objective, and
health history data with a
deep understanding.
Points – 8
Points – 9
Points – 10
Nursing diagnoses are
insufficient and/or do not fit
the data.
Failure to submit Nursing
Diagnosis will result in zero
points for this criterion.
Writes ONE NANDA-I approved
nursing diagnosis in the correct
format (including related to/as
evidenced by) with a strong
connection to identified data.
Points – 7
Points – 8
Writes TWO NANDA-I
approved nursing
diagnoses in the correct
format (including related
to/as evidenced by) with
a strong connection to
identified data.
Points – 9
Writes THREE NANDA-I
approved nursing diagnoses
in the correct format
(including related to/as
evidenced by) with a strong
connection to identified
data.
Points – 10
Writes ONE goal for
TWO nursing diagnoses
and the goals meet all
the SMART goal
guidelines and are
related to the nursing
diagnoses.
Points – 13
Writes ONE goal for THREE
nursing diagnoses and the
goals meet all the SMART
goal guidelines and are
related to the nursing
diagnoses.
Criteria
Assessment / Data
Collection
(10 Pts)
Nursing Diagnosis
(should fit the data)
(10 Pts)
The goals meet few SMART goal
SMART Goal (should guidelines and/or are not
related to the nursing
reflect the diagnosis
diagnoses.
and follow guidelines) Failure to submit SMART goals
will result in zero points for this
(15 Pts)
criterion.
Points – 11
Writes ONE goal for ONE nursing
diagnosis and the goal meets all the
SMART goal guidelines and are
related to the nursing diagnosis.
Points – 12
Points – 15
Interventions and
Rationale
(20 Pts)
APA Citation
(5 Pts)
Lacks appropriate interventions
and rationale to assist the client
in resolving the issues leading
to the problem.
Failure to submit Interventions
and Rationale will result in zero
points for this criterion.
Writes 3 interventions with rationale
to assist the client in resolving the
issues leading to the problem with
appropriate references.
Writes 5 interventions
with rationale to assist
the client in resolving
the issues leading to the
problem with
appropriate references.
Writes 3 interventions with
rationale to assist the client
in resolving the issues
leading to the problem with
appropriate references.
Points – 15
Points – 16
Points – 18
Points –20
APA in-text citations and
references are missing.
Attempted to use APA in-text
citations and references.
APA in-text citations and
references are used with
few errors.
APA in-text citations and
references are used
correctly.
Points- 3
Points- 4
Few spelling and
grammar errors.
Points- 5
Minimal to no spelling and
grammar errors.
Points- 4
Points- 5
Points- 2
Numerous spelling and
grammar errors, which detract
Spelling and Grammar from the audience’s ability to
(5 Pts)
comprehend material.
Points- 2
Some spelling and grammar errors,
which detract from the audience’s
ability to comprehend material.
Points- 3