nursing care plan

NR 226 Fundamentals: Patient Care

REQUIRED UNIFORM ASSIGNMENT: CLINICAL CONCEPT MAP

PURPOSE This assignment is designed to extend the learner’s use of concept mapping as a tool for clinical care planning. The nursing process continues to provide the foundation for organizing information and thought, whereas the mapping becomes the process for intentional critical thinking and clinical reasoning.

COURSE OUTCOMES THIS ASSIGNMENT ENABLES THE STUDENT TO MEET THE FOLLOWING COURSE OUTCOMES. CO 1: Demonstrate the nursing process while providing basic care to individuals and families reflecting different stages of the life span in the extended care, acute care, and community-based settings. (PO #1) CO3: Demonstrate communication skills necessary for interaction with other health team members and for providing basic nursing care to individuals and families. (PO #3) CO4: Incorporate critical thinking skills into clinical nursing practice. (PO #4)

DUE DATE Refer to Course Calendar for details. The Late Assignment Policy applies to this assignment.

TOTAL POINTS POSSIBLE 100

REQUIREMENTS

Choose an individual for whom you perform nursing care in the clinical setting. After performing a complete assessment of the person, create a concept map. You will use the nursing process to map your findings, create and prioritize nursing diagnoses, plan interventions, and evaluate outcomes of those interventions. Use at least two published nursing references (other than textbooks) to support your plan of care.

In addition to the concept map and in relationship to it, you will submit a one‐page reflective pape r that addresses communication and safety and infection control. Based on your clinical experience with the person for whom you provided care, you will reflect on specific elements of communication used during your interaction. Finally, you will discuss issues of safety and infection control related to the care of the person. Refer to the grading rubric for the detailed expectations regarding content.

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PREPARING THE ASSIGNMENT To prepare the concept map, you may use any software of your choosing. Your textbooks and the Internet may

offer access to simple and free concept map creation tools. Although you may select any format for the

assignment, all aspects of the assignment must be included, and the parts of the map must be clearly labeled.

There is also a concept map template located in the Unit 1 assignment page of this cour se. Be sure to check with

your faculty on the preferred format/template.

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DIRECTIONS AND ASSIGNMENT CRITERIA

Assign me nt

Criteria

Points % Descript io n

Individual’s Information

10 10% Include age, medical diagnoses, and brief pathophysiology review.

Assessment Data 15 15% Include all assessment data, not simply information that supports the selected nursing diagnoses.

Nursing Diagnoses 15 15% Select three nursing diagnoses. At least one must be an actual problem, and one must address a psychosocial need.

Linkages Between and Among Diagnoses

5 5% Concept map demonstrates relationship within and between the nursing diagnoses.

Planning 15 15% Prioritize the diagnoses to reflect needs of the individual. Set realistic outcome goals.

Implementation 15 15% Interventions are appropriate and will help individual achieve stated outcome goals.

Evaluation of Outcomes

5 5% Evaluate the individual outcomes that were developed during planning. Were outcomes met or not? (It is OK to not meet outcomes, just explain why and what adjustments will be made.) Why were outcomes met? Do not simply say “Outcome met.”

Reflection: Communication

8 8% Therapeutic and nontherapeutic, verbal and nonverbal communication are analyzed; improvement measures are addressed.

Reflection: Safety 8 8% Safety and infection control are explored.

Writing Mechanics and APA

4 4% Proper APA format, grammar, writing mechanics and spelling

Total 100 100%

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GRADING RUBRIC

Assignment Criteria

Outstanding or Highest Level of Performance

A (92–100%)

Very Good or High Level of Performance

B (84–91%)

Competent or Satisfactory Level of Performance

C (76–83%)

Poor, Failing or Unsatisfactory Level of Performance

F (0–75%)

Individual’s Information (10 points)

Incl udes all bulleted points  Age  Medi cal

diagnoses

AND Informati on in bulleted points is correct.

Revi ew of pathophysiology is thorough, accurate, and brief.

10 points

Incl udes two bulleted points  Age  Medi cal

diagnoses

AND Informati on in bulleted points is correct.

Revi ew of pathophysiology is thorough and accurate, though not bri ef.

9 points

Incl udes one of the bul leted poi nts

 Age  Medi cal

diagnoses AND

Informati on in bulleted points is correct.

Revi ew of pathophysiology is accurate, though not thorough or bri ef.

8 points

Incl udes none of the bul l eted points

 Age  Medi cal

diagnoses OR

Informati on in one or more bul l eted points i s i ncorrect.

Revi ew of pathophysiology is accurate, though not thorough or bri ef.

0–7 points

Assessment Data

(15 points)

92–100% of assessment data col l ected i n the cl inical setti ng are reported wi thin concept map.

14–15 points

84–91% of assessment data col l ected i n the cl inical setti ng are reported wi thin concept map.

13 points

76‐83% of assessment data col l ected i n the cl inical setti ng are reported wi thin concept map.

12 points

75% or less of as s essment data col l ected i n the cl inical setti ng are reported wi thin concept map.

0–11 points

Nursing Diagnoses

Three total di agnoses are accuratel y mapped.

 At l eas t one di agnosis i s an actual probl em.  At l eas t one di agnosis is a

ps ychosocial issue. 14–15 points

Two total di agnoses are accuratel y mapped.

 At l eas t one di agnosis i s an actual probl em.  At l eas t one di agnosis is a

ps ychosocial issue. 13 points

One di agnosis is accurately mapped.  Mapped di agnosis i s ei ther an

actual problem or a ps ychosocial issue.

12 points

No di agnoses are mapped. OR One to three total di agnoses are mapped i ncompletel y and/or do not i ncl ude an actual probl em or psychosocial issue.

0–11 points

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(15 points total; 3 required worth 5 points each)

Linkages Between and Among Diagnoses (5 points)

 Concept map demonstrates rel ationship within and between the nurs i ng di agnoses.

AND  Legend i s i ncluded.

5 points

This category is either complete and receives full credit or is incomplete and receives no credit.

 Concept map does not demons trate rel ationship wi thi n and between the nurs ing diagnoses.

OR  Legend i s not i ncluded.

0 point

Planning (15 points)

 Diagnoses prioritized to reflect needs of the individual

AND  Outcomes clearly defined

14–15 points

 Diagnoses prioritized in a general manner not reflecting the needs of one individual

AND  Outcomes clearly defined

13 points

 Diagnoses prioritized in a general manner not reflecting the needs of one individual

OR  Outcomes clearly defined

12 points

 Diagnoses not prioritized

AND  Outcomes not defined

or unclear 0–11 points

Implementation (15 points)

 Interventi ons are appropriate wi th supported rati onales .

 Interventi ons will hel p i ndi vidual achieve s tated outcome goals.

14‐15 points

 Interventi ons are mos tly appropriate wi th s upported rationales.

 Interventi ons may hel p i ndi vidual achieve s tated outcome goals.

13 points

 Interventi ons are appropriate wi th some rati onales present.

 Interventi ons may hel p i ndi vidual achieve s tated outcome goals.

12 points

 Interventi ons are not appropriate and/or rati onales are not provided.

 Interventi ons will not hel p i ndividual achieve s tated outcome goals.

0–11 points

Evaluation of Outcomes

(5 points)

 Outcome attainment thoroughly eval uated

 Evi dence provided s trongly s upports eval uation of

 Outcome attainment parti ally evaluated

 Evi dence provided moderatel y supports eval uation of outcome s tatus

 Outcome attainment mi ni mally evaluated

 Evi dence provided weakl y s upports eval uation of outcome s tatus

 Outcome attainment NOT eval uated OR

 Evi dence provided does not s upport evaluation of outcome s tatus OR

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outcome s tatus  Pl an updated for

thos e outcomes not met

5 points

 Pl an updated for thos e outcomes not met

4 points

 Pl an updated for thos e outcomes not met

3 points

 Pl an not updated for thos e outcomes not met

0–2 points

Reflection: Communication (8 points)

Al l poi nts addressed i n paper  Therapeutic

and nontherapeutic communi cation analyzed.

 Verbal and nonverbal communi cation analyzed.

 Areas for i mprovement i n own communi cation patterns i denti fied

 Improvement plan outlined

8 points

Three poi nts addressed i n paper  Therapeutic

and nontherapeutic communi cation analyzed

 Verbal and nonverbal communi cation analyzed

 Areas for i mprovement i n own communi cation patterns i denti fied

 Improvement plan outlined

6 points

Two poi nts addres s ed i n paper

 Therapeutic and nontherapeutic communi cation analyzed.

 Verbal and nonverbal communi cation analyzed.

 Areas for i mprovement i n own communi cation patterns i denti fied

 Improvement plan outlined 4 points

Zero or one poi nt addressed i n paper  Therapeutic and

nontherapeutic communi cation analyzed.

 Verbal and nonverbal communi cation analyzed.

 Areas for i mprovement i n own communi cation patterns i denti fied

 Improvement plan outlined

0–3 points

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Reflection: Safety

(8 points)

 Identi fies s afety hazards present bas ed on i ndividual’s condi tion and nurs ing diagnoses s el ected

AND  Identi fies i nfection

control i s s ues pres ent bas ed on

i ndi vi dual ’s condi ti on and

nurs ing diagnoses s el ected AND

 Refl ects on ways in whi ch the nurse can decrease thes e risks to i ndividuals i n thei r care

8 points

 Identi fies s afety hazards present bas ed on i ndividual’s condi tion and nurs ing diagnoses s el ected

OR  Identi fies i nfection

control i s s ues pres ent bas ed on

i ndi vi dual ’s condi ti on and

nurs ing diagnoses s el ected AND

 Refl ects on ways in whi ch the nurse can decrease thes e risks to i ndividuals i n thei r care

6 points

 Identi fies s afety hazards present bas ed on i ndividual’s condi tion and nurs ing diagnoses s el ected

OR  Identi fi es i nfecti on control

i s s ues pres ent bas ed on

i ndi vi dual ’s condi ti on and

nurs ing diagnoses s el ected OR

 Refl ects on ways in whi ch the nurse can decrease thes e risks to i ndividuals i n thei r care

4 points

 Does NOT i denti fy s afety hazards and i nfecti on control i s s ues based on i ndi vidual’s condition and nursing di agnoses s elected

AND  Does NOT refl ect

on ways i n which the nurs e can decrease thes e ri s ks to i ndividuals i n thei r care

0–3 points

Writing style, APA format, grammar, spelling, mechanics

(4 points)

Al l criterion i tems are met:  Fl ow of i deas logical and

eas y to fol low  Ideas are presented clearly  APA formatti ng free of

errors  Incl udes reference l ist and

i n-text ci tations  Spel l ing, grammar, and

mechani cs are free of errors

4 points

Di d not meet one (1) of the cri terion i tems:

 Fl ow of i deas logical and eas y to fol low

 Ideas are presented clearly  APA formatti ng free of

errors  Incl udes reference l ist and

i n-text ci tations  Spel l ing, grammar, and

mechani cs are free of errors

3 points

Di d not meet two (2) of the cri terion i tems:

 Fl ow of i deas logical and eas y to fol low

 Ideas are presented clearly  APA formatti ng free of

errors  Incl udes reference l ist and

i n-text ci tations  Spel l ing, grammar, and

mechanics are free of errors

2 points

Di d not meet three (3) or more of the cri terion i tems:

 Fl ow of i deas logical and eas y to fol low

 Ideas are presented clearly  APA formatti ng free of

errors  Incl udes reference l ist and

i n-text ci tations  Spel l ing, grammar, and

mechani cs are free of errors

1 point

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Total Points Possible 100 points

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