Care Plan

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1111 Rubric Assessment - NUR4641--03:Adult Health N111Sing II (2022 Somrner'fenn l )- :.-;378 - &."Surret;tiarj l'Jn~tr - Gopgle €hrome X

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'1'1 11 18 Print Rubric

Good Fair Poor Incomplete 4 points 3 paints 2 points 11,i O points

- - - -------t-------~ --i-----------+--- __ __ ___,,L:wL .. __ ___ _ _ Criteria

Criterion Score

Patient information and health assessment: Complete patient demographics, health assessment and inte rvent ions

Pert in ent Dia g)1os tic _Dat1: __

All of the demographic section is completed, all areas of the health assessment is completed interventions1 are identified for ~h1e ,,, health assessment data that is identified.

Identified al l of the abnormal

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11 11

Approximately , Minimal 1,,,I\I. half to 2/3rds of ' 1\111 demograph jc th d h• i f . 11111 . e emograp 1c n

I . 1 ormatio n 1s

section is I11'1'1i\11' '' p~Jl~iped ini'ii~e ,

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complete. Tl;ie 1 11\1 \11 ,care plan, ma l'.Jy • I 1I1I '' I, 11\1,'1 l1l'i'I

'11\1i'il 111 I

health lj:ISSessr:hent a~ea!i l1<',~Ithe 1111 1 1,1 ,I ''111'1 I i'1111 \11\lh, 'l1'1lI1', 1I I Iis 1at least 1~a lf 11,\1 I l11 t\1~1alth a1s~ess~ent , , I 11'1 " i11li1\11 '· I I I 111111111' ,' l111 l1l1'

1 1 complete and l!i ' 1\ 1,\ 11\1 seatio n a~f:! 1 1 11 j

' I 'I ifl1 1111 l11I 'l11\'l aacuratel',1 1 1/,/ I I1ii1i111o mitted, I 1i 11 1\ ,· I 1,\1,1," I 1111'111, l1 1<1 1 idenMied 111 11 1

1 11 11111 \ i'nte rve ntiops areI I I Ill\ 11, I I 1111 I aftlloughi'i!i11ini~Ial 11 \I \ lim ited . I'

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1· 1nterve 'ltion~I,ar~ 111\1' 11 1\11 1 11 'l\I

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,, 1, still ,\1ot~f!, bas11~1 ,1, \11 11 , 1'11111' '1i1/\1 , ,

No Demographic info~mation is

noted in the care l'l 11' pla'n; health 1I 1I

assessment and 1'1l11

interventions are I

not identified 1 I ' i1

correctly. ,1 I'

on th ~' h~~lth l1,\l11' I 1111'1I\ 11\11,1 1\\,1\1, '\1, 1\I Ii ," '\ 1,111[1 ,i1,11, I 1

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Pertinent Identified all of Identified all of Identified half of No Diagnostics /4 Dia gnostic Data: the abnormal the abnormal the abnormal were identified Identify abnormal diagnostics and diagnostics and diagnostics and for this patient. diagnostics, state stated the wa~able to state was able to state significance for significance fo r SOME of the SOME of the this patient. this patient. significance for significance for

this patient. this patient.

Number of Identified 5 Identified 4 Identified 3 I Identified 2 /4

Nu rsing nursing diagnoses nursing diagnoses nursing diagnoses I nursing diagnoses Diagnoses: for the patient for the patient for the patient I for the patient Provided 5 that are correct that are correct that are correct that are correct correct nursing based on the based on the based on the I based on the diagnoses for the patient patient patient I patient patient based on 11 a~~essment, assessment, assessment, I assessment, the patient histo ry and data history and data history and data history and data. health 1i ,, I assessment ,

,',,I history, labs, and , pathophysio logy. I

. I ..... j'" ······- -· ----

Pathophysiology: Explanation of No explan ation of No explanation of Not identified / 4

Disease process pa t hophysiology pathophysiology patho phys iology co rrectly or I h . chosen ;__g~ D,,.Yid.tl;L,-._,fj1os.~1,K_g ive n r ..£Q!L~ctLv . ~-.Ji.e.scr.i.oiino ____________ ---~ .. 9.S .. f;\D_;_gJve n

Pathophysiology: Disease process descri ption including "Signs and Symptoms" as well as APA references cited

Pharmacology: Complete and accurat e description of current med ication list t hat includes

1 descripti on of medications, side effe cts as w ell as nursing con siderations

Explanation of pathophysiology chosen; given with accurate details related t o cl ient's symptoms and current illness. APA references noted

List all MAR meds with description, side effects and nursing cons iderations

. . spec1f1 c to pat ient and w hy patient is receivi ng drug

No explanation of No explanation of pathophysiology pathophysiology chosen; given with chosen ; given acctl rate details with accurate related to client's details related to symptoms and client's symptoms current illness. and current APA references illness. No APA noted references not ed

Most of t he MAR I List some MAR meds wit h

I meds but does

description, side not inclu de effects and I relevant side nursing effec t s and considerat ior. 5 nursing specific to patient con siderations and why patient is I spec ific to patient rece ivi ng drug

I I

Not identified correctly or correctly identified although w ith many omissions not ed. The pat hophysiology is not integrated into the plan of ca re

---

Only some of the current meds are written & discussed in the meds section. Info is incomplete w ith many omissions noted. The meds are not integrated in t he plan of care

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Nursing Diagnosis is Diagnos is is Diagnosis is not Diagnosi s /4 Diagnosis: appropriate for appropriate for appropriate for sel e cted reflects (I ncludes all 5 Dx) patient/priority patient/priority patient and that no effort to Reflects t he level. NANDA level. NANDA priority level. May interpret info was primary diagnosis approved. app~oved. Does also not be applied resul t ing and is Diagnosis also not include all NANDA approved in a flawed plan of appropria t e for includes all parts parts or info is and may not care. NANDA patient scenario and information listed in wrong include all parts format is not as well as priority part of diagnosis complete or used level. Expressed in acceptable correctly

NANDA format. Also includes all parts stem, R/T, and AEB

Assessment: Includes all Includes all Appropriate for pertinent data Doesn't include all Not a ll relevant /4 chosen diagnosis.

pertinent data pertinent rela t ed subjective & related to nursing Includes Ox., and does not

related to n ,rsin g d ata to nursing objective data is Dx., but also obj ective & include data that includes d at a not Ox. M ay include collected. There is

subjective is not related to relate to Ox d at a not relating

an absence of the historic al data Ox to D x use o f inquiry to that support

collect info actu al or risk for

relevant to the ..... , ... ,,.. ; ..... .,... ...-, : ,..., .... ...,."'-"'";,.. individua l 's ..

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I /4 & A ssess ment: Includes all Includes all Doesn 't include all Not all relevant

Appropriate for pertinent data pertinent data pertinent related subjective & chosen diagnosis. related to nursing rela ted to nursi ng data to nurs ing objective data is Includes Dx ., and does not Dx. , but also Dx. May include co ll ected. There is objective & include data that inc.[µdes data not data not relating an absence of the subjective is not related to relate to Dx to Dx use of inquiry to historical data Dx coll ect info that support re leva nt to the actual or risk for individual's nursing diagnosis disease &

circumstances. I ___ I_

Patient Outcomes Outcomes I Doesn 't include all Does n't include /4 Outcomes statement is I statement is pertinent related many of the I Out comes shou ld I specific to pt. Dx. specific to pt. Dx ., data to the needed be specific to the and contai ns all 4 but also includes nursing Dx. May measurable patient Dx., The I measurable data not rela t ed to also include data criteria. Outcome outcome criteria Dx. not relating t o the is not specific to statement shou ld patient Ox. It only the pat ient. also contain the I contains two of following 4 I the 4 measurable

I criteria : criteria. I measurable, a I attainable, I

rea listic, an d y

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Int erventions : Include

interventions or nursing actions t hat directly relate to the patient's goa l; are specific in action , frequency and contain rationale. The number of interventions should be appropriate to

I hep patient/family meet thei r goa l

Evaluation : Incl ude s a ll data that is liste d as criteria in outcome statement Based

Intervention Interve ntion portion contains portion contains an adequate an ia dequate numbe r of t number of interventions to interventions to help the help the patient/family patient/family meet their goal. meet their goal. The interventions The interventions are specific in may not be action and specific in action frequency, and are and frequency, also listed with and may not be rationales. la beled w ith

o r li sted with ration a les.

------· ---- . -· -----

Eva luation po rtion does contain data that is listed a s criteria within the goal statement. Does descri be the

Eva lua t ion portion does conta in data that is listed as criteria within the outcome statement,

Interventio n portion doesn't include an adequate number of interventions to help the patient/fam ily meet their goal. May also not be specific, labeled or listed with rationales.

Evalua t ion portion does not conta in data that is listed as criteria in the outcome sta ~~ ment. Ma y

Inappropriate interventions are included in the plan of care, interventions are not realistic & appropriate to the patient's current status.

Does not clearly evaluate if the outcome is met; evaluation is purely based on if interventions are

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patient/fa mily meet their goa l

Eval uation: Includes all dat a t hat is listed as crit eria in outcome 11

statement. Based I

on this data, outcom ~ is determined to be I '

'hlet, partially met, or not met. If is not met or partially met, plan of care is revised or continued and a new eva luation date

Total

Evaluation portion does contain d? ta that is listed as criteria within the goal statement. Does describe the outcome as met, partially met, or not met, includes revision of p lan of care, or new evaluation date/time.

rationales.

Evaluation portion does contain data that is listed as criteria with in the outcome statement, but does not describe the goal as met, partially met, or not met. May not include a revision of plan of care, or new evaluation date/time.

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Eva luation portion does not cont ain data that is listed

Does not clearly evaluate if the outcome is met;

as criteria in the evaluation is outcome purely based on if statement. May interventions are also not describe applied to goal as met, · patients care. partially met, not met. May also not include revision or new eva lua tion I date/time. /

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