Joanne just celebrated her 50thbirthday and knows that she should probably see her physician for a physical. She’s generally in good health, but has been experiencing some odd symptoms lately…..
identify one (1) nursing diagnosis (clinical judgement) related to Lucas’ psychosocial, spiritual or cultural well-being, based on the cues you identified in step 3.
1. Review the ‘Episode of care – Lucas’ page in ‘Assessment 1’ module on Canvas. This is where
you will find the clinical case information.
2. Using the case information, complete a psychosocial assessment using the ‘Formulation
Framework – 5 P’s’
o Presenting problem
o Predisposing factors
o Precipitating factors
o Perpetuating factors
o Protective factors
3. Identify case relevant ‘cues’ based on steps 1 & 2.
4. Using the ‘Nursing diagnoses: definitions and classifications – 2015-17’ (NANDA-I), identify
one (1) nursing diagnosis (clinical judgement) related to Lucas’ psychosocial, spiritual or
cultural well-being, based on the cues you identified in step 3.
5. Outline two (2) priorities of care for Lucas based on your nursing diagnosis (supported with
6. Document steps 2-5 as a handwritten clinical progress note guided by the:
o Minimum Standards of Nursing Documentation
o Nursing and Midwifery Content Audit Tool (NMCAT) criteria
o Legal requirements criteria
See Johnson, Jefferies & Langdon (2010) – Table 1 (Minimum standards and NMCAT criteria)
& 5 (NMCAT legal requirements).