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Care Plan

Assignment 2: Case Study Analysis and Care Plan Creation
Click here 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 CDC, WHO, AHRQ, 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.
Click here to download the care plan template to help you design a holistic patient care plan. The care plan example provided here is meant only as a frame of reference for you to build your care plan. 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
Your care plan should be formatted as a Microsoft Word document. Follow the current APA edition style. Your paper should be 2 pages excluding the title and ther references and in 12pt font.
Name your document: SU_NSG6001_W2_A2_LastName_FirstInitial.doc.
Submit your document to the W2 Assignment 2 Dropbox by Tuesday, November 29, 2016.
Assignment 2 Grading Criteria
Maximum Points
Subjective Data
The submission included the patient’s interpretation of current medical problem. It 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 measurements and observations obtained by the nurse practitioner. It included 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
Used APA standards consistently and accurately when citing in the SOAP note and reference page. Utilized proper format with coversheet and header.

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