ASSIGNMENT: PATIENT DISEASE/DISORDER

ASSIGNMENT: PATIENT DISEASE/DISORDER

Course: NURS 317L NURSING CARE PLAN RUBRIC NURS 101L, NURS 210L-AB, NURS 317L STUDENT NAME: PATIENT INITIALS: Criteria COURSE: ___________ PATIENT DISEASE/DISORDER: 4 Exceeds Expectations History of Present Illness HPI explained in detail with accurate and in-depth understanding of chief complaint and supported by evidence based citations. Physical Assessment, & Diagnostic tests/ procedures Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations. Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and supported by evidence based citations. Past Medical & Surgical History, Pathophysiology Erikson’s Developmental Stages Page 1 of 3 DATE: Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. 3 Meets Expectations HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations. Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations. Past medical/surgical history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations. Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. 2 Approaching Expectations HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations. Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations. Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations. Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations. 1-0 Does Not Meet Expectations HPI details limited with poor understanding of chief complaint and no evidence based citations to support. Score Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations. X2 No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence. X2 Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations. X2 X2 Course: NURS 317L NURSING CARE PLAN RUBRIC NURS 101L, NURS 210L-AB, NURS 317L Criteria Socioeconomic/ Psychosocial Assessment Interprofessional Consults & Discharge Referrals Potential Health Deviations Priority Nursing Diagnosis 4 Exceeds Expectations Describes socioeconomic and cultural background in complete detail with references; Identifies 3 psychosocial concerns.
ASSIGNMENT: PATIENT DISEASE/DISORDER Lists 3 or more appropriate collaborative issues/concerns; Rationale demonstrates excellent understanding of consults and interventions. Identifies TWO prioritized risk factors in proper format; Writes 3 independent nursing interventions. TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Planning/Goals & Evaluation Goal is measureable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions. Implementation and Rationale Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using Page 2 of 3 3 Meets Expectations Describes socioeconomic and cultural background in some detail with references; Identifies 2 psychosocial concerns. Lists 2 appropriate collaborative issues/concerns; Rationale demonstrates satisfactory understanding of consults and interventions. Identifies 1 prioritized risk factor in proper format; Writes 2 independent nursing interventions. One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis. Goal is not measureable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions. Identifies 3 independent interventions with teaching; Scientific rationale is supported with scientific 2 Approaching Expectations Describes socioeconomic and cultural background in vague detail without references; Identifies 1 psychosocial concern. Lists 1 appropriate collaborative issue/concern; Rationale demonstrates vague understanding of consults and interventions. Identifies 2 prioritized risk factors but not in proper format; Writes 1 independent pertinent nursing intervention. Written incorrectly with sufficient data to support diagnosis, not a priority. Goal is not measureable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions. Identifies 2 independent interventions with teaching; Scientific rationale is 1-0 Does Not Meet Expectations Describes socioeconomic and cultural background with no detail without references; Identifies no psychosocial concerns. Lists inappropriate collaborative issues/concerns; Rationale demonstrates unsatisfactory understanding of consults and interventions. Does not identify prioritized risk factors; Writes 0-1 independent nursing intervention not pertinent to the diagnosis. Written incorrectly, not in correct format, or without sufficient data to support diagnosis. Score Goal is not measureable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions. Identifies 1 independent interventions with teaching; Scientific rationale is not X2 X1 X2 X3 X4 X2 Course: NURS 317L NURSING CARE PLAN RUBRIC NURS 101L, NURS 210L-AB, NURS 317L Criteria Medications General Organization 4 Exceeds Expectations textbook or evidence based citations. Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug. Accurate APA format; Appropriate citations & references; No spelling or grammar errors. 3 Meets Expectations rationale using textbook or evidence based citations. Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug. 1-2 APA format errors; Some citations, references are appropriate; Minimal spelling or grammar errors. 2 Approaching Expectations vaguely relevant & not supported from textbook. Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug. Many APA format errors; Inappropriate citations or references; Many spelling or grammar errors. 1-0 Does Not Meet Expectations relevant & not supported from textbook. Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient. Score No APA formatting; No citations or references included; Many spelling or grammar errors. Total X1 X2 /100 % COMMENTS: FACULTY SIGNATURE: Page 3 of 3 DATE: Course: NURS 317L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 317L Student Instructor Patient Initial Code Status Allergies Temp (C/F Site) Date Course DOB Height/Weight Unit/ Room# Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical & Surgical History, Pathophysiology of medical diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Erikson’s Developmental Stage with Rationale And supported by Evidence Based Citations Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations Page 1 of 3 Course: NURS 317L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 317L Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each (“At Risk for…” nursing dx) Diagnostic Label Priority Nursing Diagnosis (at least 2) Written in three part statement Page 2 of 3 Related to Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing diagnosis) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale supported with Evidence Based Citations Contributing Factors Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching (at least 4 per goal) As evidenced by Rationale Each must be supported with Evidence Based Citations Signs and Symptoms Evaluation Goal Met, Partially Met, or Not Met & Explanation Course: NURS 317L NURSING CARE PLAN TEMPLATE NURS 101L, NURS 210L-AB, NURS 317L MEDICATION LIST Medications (with APA citations Page 3 of 3 Class/Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient …

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