Course Project Milestone #2 Nursing Diagnosis and Care Plan Form

Chamberlain College of Nursing NR305 Health Assessment

CourseProject Milestone #2: Nursing Diagnosis and Care Plan Form


Directions:Refer to the Milestone 2: Nursing Diagnosis and Care plan guidelinesand grading rubric found in Doc Sharing to complete the informationbelow. This assignment is worth 250 points, with 10 points awardedfor clarity of writing, which means the use of proper grammar,spelling and medical language.

Typeyour answers on this form. Click “Save as” and save the file withthe assignment name and your last name, e.g.,“NR305_Milestone2_Form_Smith” When you are finished, submit theform to the Milestone 2 Dropbox by the deadline indicated in yourguidelines. Post questions in the Q&ampA Forum or contact yourinstructor if you have questions about this assignment.

1:Analyze Assessment Data:

Basedon the health history information, identify the following:

A.Areas for focused assessment (30 points)

Providea briefoverview of those areas of strength and weakness noted from Milestone1: Health History.

Theclient is well insured. She has set appropriate health eating habitsand exercising. She goes for checks-ups, even when not sick. She hasresolved to live a healthy lifestyle and ensuring her family is onappropriate diet. On the other hand, her staying at home exposes herto many chores that are unavoidable, hence inadequate time to rest.In addition, the health beliefs and practices seem to be a majordrawback, especially when making healthcare decisions. Also,exposure to second-hand smoke from her smoking husband is dangerousto her life and the life of the fetus. Additionally, her familyhistory is alarming as the mother had suffered from anemia andfibroids while the sister is suffering from high blood pressure.

B.Client’sstrengths (30 points)

Expandon areas identified as strengths related to the person`s overallhealth. Support your conclusions with data from the textbook.

Theclient has set appropriate goals and patterns that ensure her healthremains a priority. For instance, she has endeavored to be eatinghealthy foods often, as well as exercising a lot. These are verynecessary, especially during pregnancy for proper development of thefetus and eliminates any health complications to the mother. Herhabits and traits in matters to do with health are encouraging. Shehas taken it upon herself to ensure that her family is on a healthydiet, taking a lot of water and exercising when possible. This isvery critical to any family and ensures that health remains apriority. Taking the necessary steps towards insuring oneself is amajor strength. This will ensure that she is always guaranteed incase of any emergency. The client has endeavored to take healthymeals and exercises a lot, particularly from the time she conceived,and this is crucial for her health and development of the baby.

C.Areas of concern (30 points)

Expandon areas previously identified as abnormal and those that place theperson at a health risk. Support your observations with data from thetextbook.

Fora pregnant woman, working may not be a problem, but overworkingexposes her to certain dangers. For instance, LM stays at home alltime, hence having many chores. This means that she never gets enoughtime to eat, and probably cook as she notes that she finds herselftaking snacks instead of food. This is risky as the growing fetusrequires proper nutrients for healthy development. From her familyhistory, it is noted that the client`s mother had suffered fromanemia and fibroids while the sister is suffering from high bloodpressure. This means that the client may be in danger of sufferingfrom fibroids, high blood pressure, and anemia.

D.Health teaching topics (30 points)

Identifyhealth education needs. Support your statements with facts from theHealth History and information from your textbook.

Amongthe major education needs are the healthy eating habits. Duringpregnancy, a woman is not supposed to be taking snacks for her meals.Also, education on the need for free time and rest is critical. LMfinds herself too much occupied to rest. Studies indicate that therest is critical, especially during pregnancy. People should bemobilized on realistic healthcare beliefs and practices. Thoughvarious people have different beliefs and practices, some of themhinder delivery and search for appropriate healthcare. It isnecessary that the some practices that hinder proper healthcarepractices be done away with. The client needs to be enlightened onproper control measures that can reduce the prevalence to certainsicknesses and disorders that are common among pregnant women.

2:Nursing Care Plan

Next,plan your care based on your analysis of your assessment data:

A.Diagnosis (30 points)

Writeonenursing diagnosis that reflects a priority need for this person. Remember a wellness diagnosis is a possibility.

Wellnessdiagnosis is necessary for the client. A wellness diagnosis helps indescribing the responses of the person willing to enhance her health.This is critical especially because the client, LM, is ready toadvance from her current health level to a higher level. As it can benoted, LM has endeavored to maintain a healthy diet and she exercisesa lot. She believes that wellbeing starts with the individual, andthis is an indication that the wellness diagnosis is the best optionfor her. Twomajor prerequisites for a wellness diagnosis include the desire toadvance one’s health and the ability to do achieve that. Thewellness diagnoses are useful in the pregnancy areas which lie withinthe normal limits, and enable women mobilize their strengths whendealing with abnormal components. In wellness diagnoses, the mothermust be ready to deal with changes caused. This may involve seekingmedical care, some physical changes may impede the daily routines,and the womanhood role must be redefined as a result of thepregnancy.

B.Plan (30 points)

Writeone goal and one measurable expected outcome related to your nursingdiagnosis. Explain why this goal and outcome is a priority. Includecultural considerations for this client.

  • Goal: To provide as normal an outcome as possible and empower on the need for healthy pregnancy period

Thisgoal is a priority as the patient has not been so much keen on restand proper eating habits. Therefore, it is the responsibility of thenursing practitioner to educate the client on the need to ensure ahealthy lifestyle by making it a norm to eat well and take enoughrest.

Outcome:By the end of the pregnancy period, the client will deliver a healthychild without any complications.

Thisoutcome is a priority since the mother is currently at 21 weeks,suffering from anemia and fibroids. Therefore, it was be the goal ofall parties involved, including family members to ensure that themother stays healthy, stress free and carries the pregnancy to termwithout any complications.

C.Intervention (30 points)

Writeas many nursing orders or nursing interventions that you need inorder to achieve the outcome. Provide the rationale for eachintervention listed.

  • Caution the husband to the client to stop smoking

Thehusband should stop smoking, if not, ensure that he does not smokenear the wife. Medically, second-hand smoke is very dangerous,especially for the developing fetus and may lead to complications.

  • Advocate for healthy eating habits

Theclient should ensure that she does not take snacks in place of food.Healthy diet is critical in fetus development.

  • Warn the client of dangers of not taking rest

Mostwomen continue with their normal tasks during pregnancy. To stayhealthy, pregnant women must understand in appropriate ways ofalleviating common pregnancy discomforts. There is the need tounderstand when the work task jeopardizes the pregnancy.

  • Advocate for regular medical checks

Fromthe family history, the client`s sister suffers from high bloodpressure while the mother had anemia and fibroids sometimes back. Sheis currently suffering from anemia and fibroids that her mother wassuffering from. This implies that the client is prone to high bloodpressure just like her sister. The nurse in charge should ensureregular check-ups for blood sugar levels to ensure that proper care,as well as protect the client against blood pressure.

D.Evaluation (30 points)

Youwill not carry out your care plan so you cannot evaluate theeffectiveness of your nursing interventions. Instead, comment on whatyou would look for in order to evaluate your effectiveness.

  • Changes in blood pressure levels

  • Abrupt changes in weight of the client

  • Changes in physical appearance and complexion of the client

  • Limited or no complaints and discomforts from the client

  • Reports on reduced or no smoking from the client’s husband

  • Desire by the client to consult regularly as she was used to consulting twice a year.


D’Amico,D., &amp Barbarito, C. (2011). Health&amp physical assessment in nursing (2nd ed.).Upper Saddle River, NJ: Prentice Hall.

Milestone #2: Nursing Diagnosis and Care Plan Form8-6-13 jm


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