Care plan and concept map

Assessment

Performance Element

Student Learning Outcome

Unsatisfactory

1

Developing

2

Adequate

3

Good

4

Excellent

5

Comments

Recognizing and Analyzing Cues

Introduction: 5 elements

· Summary of patient’s profile.

· History of present illness

· Signs and symptoms

· Past medical/surgical history.

· Head to Toe complete and attached.

1,3

One or none of the five elements are completed and thorough.

Two out of five elements are completed and thorough.

Three out of five elements are completed and thorough.

Four out of five elements are completed and thorough.

All five elements are completed and thorough

Pathophysiology presented in the form of a concept map to include these four elements: medical diagnosis, signs and symptoms, potential complications, and

expected treatment (with references)

1,3

Missing and/or no references provided.

Limited description of the four elements.

Partially and accurately described all four elements

Adequately and accurately described all four elements

Thoroughly and accurately described all four elements

Laboratory findings to include the following: Normal value, client’s value, and clinical significance of abnormal values (with references).

1,3

Four or more elements missing or inaccurate

Three elements missing or inaccurate

Two elements missing or inaccurate

One element missing or inaccurate

All elements are accurate and completed

Medication list to include the following: Order, dose range, mechanism of action, indication, side effects, and nursing considerations (with references and rationales)

1,3

Four or more elements missing or inaccurate OR no references provided

Three elements missing or inaccurate.

Two elements missing or inaccurate.

One element missing or inaccurate.

All elements are accurate and completed

Problem Statements

Formation of first/ priority problem statement from assessment data.

(Elements to include problem/diagnostic label, “related to,” and “as evidenced by”) 

4

No elements completed accurately with correct prioritization as primary problem.

One out of three elements completed accurately with correct prioritization as primary problem

Two out of three elements completed accurately with correct prioritization as primary problem

All elements completed accurately but NOT correct prioritization as primary problem

All elements completed accurately with correct prioritization as primary problem

Formation of second nursing problem statement from assessment data.

(Elements to include problem/diagnostic label, “related to,” and “as evidenced by”) 

4

No elements completed accurately with correct prioritization as secondary problem.

One out of three elements completed accurately with correct prioritization as secondary problem

Two out of three elements completed accurately with correct prioritization as secondary problem

All elements completed accurately but NOT correct prioritization as secondary problem.

All elements completed accurately with correct prioritization as secondary problem.

Formation of third nursing problem statement from assessment data.

(Elements to include problem/diagnostic label, “related to,” and “as evidenced by”) 

4

No elements completed accurately with correct prioritization as tertiary problem.

One out of three elements completed accurately with correct prioritization as tertiary problem

Two out of three elements completed accurately with correct prioritization as tertiary problem

All elements completed accurately but NOT correct prioritization as tertiary problem.

All elements completed accurately with correct prioritization as tertiary problem.

Generate Solutions

3 total goals: 2 short term, 1 long term per problem

Specific goals that are behavioral, measurable, and time specific as to what the patient will accomplish

4

10+ errors in/omission of elements addressed for each goal throughout care plan

7-9 errors in/omission of elements addressed for each goal throughout care plan

4-6 errors in/omission of elements addressed for each goal throughout care plan.

1-3 errors in/omission of elements addressed for each goal throughout care plan.

All 3 elements addressed accurately for each goal throughout care plan

Specific goals that are realistic, attainable, and appropriate for patient’s needs

4

10+ errors in/omission of elements addressed for each goal throughout care plan

7-9 errors in/omission of elements addressed for each goal throughout care plan

4-6 errors in/omission of elements addressed for each goal throughout care plan

1-3 errors in/omission of elements addressed for each goal throughout care plan

All 3 elements addressed accurately for each goal throughout care plan.

Prioritized goals based on Maslow’s or Erikson’s Theory.

4

Goals are not prioritized, and/or the student does not list the Maslow’s or Erikson’s Theory in any goals

1 out of 3 goals are prioritized and correct using Maslow’s or Erikson’s Theory

2 out of 3 goals are prioritized and correct using Maslow’s or Erikson’s Theory

All 3 goals are prioritized in the correct order; however, 1 or more Maslow’s or Erikson’s Theory is not chosen appropriately.

All 3 goals are prioritized in the correct order and accurate Maslow’s or Erikson’s Theory chosen

Take Action

Related to the goal/outcome.

4

8 or less nursing interventions are related to the goal stated

9-14 nursing interventions are related to the goal stated

15-20 nursing interventions are related to the goal stated

21-26 nursing interventions are related to the goal stated

All 27 nursing interventions are related to the goal stated

Specific and include frequency.

4

8 or less nursing interventions are specific and include frequency

9-14 nursing interventions are specific and include frequency

15-20 nursing interventions are specific and include frequency

21-26 nursing interventions are specific and include frequency

All 27 nursing interventions are specific and include frequency

Prioritized in order of performance.

4

More than 3 errors in prioritizing nursing intervention or student chose nonpriority nursing interventions

3 errors in prioritizing nursing interventions

2 errors in prioritizing nursing interventions

1 error in prioritizing nursing interventions

All nursing interventions for each goal are correctly prioritized in order of performance and are appropriate for patient problem

Includes 3 interventions per goal, 2 of 3 interventions must be independent nursing actions.

4

Less than 9 nursing interventions given, at least less than 6 are independent nursing actions

9-14 nursing interventions given, at least 6-9 are independent nursing actions

15-20 nursing interventions given, at least 10-13 are independent nursing actions

21-26 nursing interventions given, at least 14-17 are independent nursing actions

27 nursing interventions given, at least 18 of which are independent nursing actions

Rationales

Rationales (one per intervention) are specific to the goals and interventions stated.

4

Less than 9 nursing interventions provides specific rationales

9-14 of the nursing interventions provide specific rationales

15-20 of the nursing interventions provide specific rationales

21-26 of the nursing interventions provide specific rationales

All nursing interventions provide specific rationales

Rationales are accurate and reflect evidence-based practice, referenced from textbook, including page numbers.

4

Less than 9 rationales are accurate and reflect evidence-based practice and include reference with page number

9-14 of the rationales are accurate and reflect evidence-based practice and include reference with page number

15-20 of the rationales are accurate and reflect evidence-based practice and include reference with page number

21-26 of the rationales are accurate and reflect evidence-based practice and include reference with page number

All rationales are accurate and reflect evidence-based practice and include reference with page number

Evaluate Outcomes

Each goal evaluated to include two elements:

· Nursing care provided (narrative documentation of interventions)

· Patient’s response/Expected response to interventions.

4

Student did not evaluate any of the goals

Missing a total of 3 evaluation elements across all goals

Missing a total of 2 evaluation elements across all goals

Missing a total of 1evaluation element across all goals

Complete evaluation of each listed element for all goals

Presentation

Appropriate use of medical terminology, grammar, spelling, neatness, and APA formatted reference page included

2

9 or more errors or reference page not included

7-8 errors in presentation

5-6 errors in presentation

3-4 errors in presentation

0-2 errors in presentation

Final Grade

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