NR305: Health Assessment for the Practicing RN

Course Project Milestone 2: Nursing Plan of Care

Assignment Brief and Guidelines

This assessment requires the development of a professional nursing plan of care based on the comprehensive health history collected during Milestone 1. The focus is on synthesizing subjective data to identify health priorities, formulate accurate nursing diagnoses, and propose evidence-based interventions suitable for a practicing RN’s clinical environment.

Assessment Task Details

• Total Pages: 3–5 pages (excluding title and reference pages).

• Word Count: Approximately 825–1,050 words.

• Format: APA 7th Edition (Professional Standards).

• Due Date: Week 5, Sunday by 11:59 p.m. MT.

Instruction Requirements

1. Data Analysis: Review the health history narrative from Milestone 1. Identify three priority health concerns (one physiological, one psychosocial, and one educational/preventative).

2. Nursing Diagnosis: Create one NANDA-I formatted nursing diagnosis for the highest priority concern. Use the “Related To” (etiology) and “As Evidenced By” (defining characteristics) format.

3. SMART Goals: Develop one patient-centered, measurable goal that is realistic for the patient’s current developmental stage.

4. Interventions: Detail three specific nursing interventions. Each intervention must be supported by a rationale grounded in current peer-reviewed literature.

5. Evaluation: Describe the specific criteria you will use to determine if the goal was met, partially met, or not met.

Grading Rubric Summary

• Diagnosis Accuracy (20%): Diagnosis aligns logically with subjective data findings.

• Planning & Goals (20%): Goals are measurable and time-bound.

• Evidence-Based Interventions (30%): Rationales cite scholarly sources published within the last 5 years.

• Clinical Reflection (20%): Thoughtful appraisal of communication barriers and interview successes.

• APA & Mechanics (10%): Professional writing, correct citations, and zero grammatical errors.

Effective health assessment requires more than just recording data; it demands a critical synthesis of the patient’s lifestyle, history, and current physical state. By isolating the relationship between chronic stressors and physiological symptoms, clinicians can move beyond surface-level care. This plan prioritizes the patient’s self-reported fatigue by linking it to documented sleep hygiene deficits and professional demands.

Learning Materials and Resources

• American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

• Hany, M., & Rehman, B. (2023). Nursing diagnosis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557456/

• Jarvis, C., & Eckhardt, A. (2024). Physical examination and health assessment (9th ed.). Elsevier.

• Toney-Butler, T. J., & Thayer, J. M. (2023). Nursing process. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499937/

• Zaccagnini, M., & Pechacek, J. M. (2021). The doctor of nursing practice essentials: A new model for advanced practice nursing (4th ed.). Jones & Bartlett Learning.