nursing care plan
kicki06
CriteriaRatingsPts.docxCriteriaRatingsPts
This criterion is linked to a Learning OutcomeAssessment & History of Present Illness
Recognizing cues focused on observation
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4 pts Proficient HPI explains in detail with accurate and in- depth understanding of chief complaint and supported by evidence-based citations. |
3.04 pts Acceptable HPI explains in some detail with moderate understanding of chief complaint or no support from evidence-based citations. |
2.4 pts Needs Improvement HPI explains in limited detail with insufficient understanding of chief complaint or support from evidence-based citations. |
0 pts Unsatisfactory HPI details limited with poor understanding of chief complaint and no evidence-based citations to support. |
4 pts
This criterion is linked to a Learning OutcomeRecognizing assessment parameters
Clinical thinking and assessment cues
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8 pts Proficient Identifies the 4 imperative assessment cues and or medical diagnoses supported by evidence-based citations. |
6.08 pts Acceptable Identifies 2 imperative assessment cues and or medical diagnosis supported by evidence-based citations. |
4.8 pts Needs Improvement Identifies 1 imperative assessment cues and or medical diagnosis, vaguely supported by evidence-based citation. |
0 pts Unsatisfactory Unable to identify any imperative assessments parameters relevant to medical diagnosis and without supported evidence-based citation. |
8 pts
This criterion is linked to a Learning OutcomeInterpreting diagnostic criteria & diagnostic tests and procedures
Clinical reasoning and analysis of cues
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4 pts Proficient Clearly and accurately describes the client’s diagnostic criteria which clearly supports the chief complaints and presenting signs/symptoms. |
3.04 pts Acceptable Adequately describes the client’s diagnostic criteria which adequately supports the identified chief complaint and presenting signs/symptoms |
2.4 pts Needs Improvement Vaguely describes the client’s diagnostic criteria which vaguely supports the identified chief complaint and presenting signs/symptoms. |
0 pts Unsatisfactory Lack description of the client’s diagnostic criteria that does not support the identified chief complaint and presenting signs/symptoms |
4 pts
This criterion is linked to a Learning OutcomePast medical & surgical history, pathophysiology
Clinical judgment and recognizing cues
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8 pts Proficient Past medical/surgical history detailed with full explanation of pathophysiology for admitting diagnosis and for each diagnosis & accurate detail with specific detail related to the client’s history and symptoms and supported by evidence-based citations. |
6.08 pts Acceptable Past medical/surgical history given with partial explanation of identified admitting diagnosis and preexisting medical diagnoses, intermittent details related to the client’s history and symptoms, or not completely supported by evidence-based citations. |
4.8 pts Needs Improvement Past medical/surgical history given with minimal explanation of identified admitting diagnosis and preexisting medical diagnoses; few to no details related to the client’s history and symptoms; or not supported by evidence-based citations. |
0 pts Unsatisfactory No past medical/surgical history given or given without explanation; no admitting diagnosis and or pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence. |
8 pts
This criterion is linked to a Learning OutcomeSocioeconomic/psychosocial assessment
The impact of socioeconomic and cultural background
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8 pts Proficient Describes socioeconomic and cultural background in complete detail with references; identified 3 or more psychosocial concerns. |
6.08 pts Acceptable Describes socioeconomic and cultural background with limited detail without references; identified 1-2 psychosocial concern. |
4.8 pts Needs Improvement Describes socioeconomic and cultural background in vague detail without references; identified 1 psychosocial concern. |
0 pts Unsatisfactory Describes socioeconomic and cultural background with no detail without references; identified no psychosocial concerns. |
8 pts
This criterion is linked to a Learning OutcomeInterprofessional consults & discharge referrals
Generating outcome data for plans
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4 pts Proficient Lists 2-3 appropriate collaborative issues/concerns; rationale demonstrated satisfactory understanding of consults and interventions. |
3.04 pts Acceptable Lists 1-2 appropriate collaborative issue/concern Rationale and demonstrated limited understanding of consults and interventions. |
2.4 pts Needs Improvement Lists 1 appropriate collaborative issue/concern Rationale and demonstrated vague understanding of consults and interventions. |
0 pts Unsatisfactory Lists inappropriate collaborative issues/concerns; rationale demonstrated unsatisfactory understanding of consults and intervention |
4 pts
This criterion is linked to a Learning OutcomeRisk assessment
Interpreting risk data analyses of cues
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4 pts Proficient The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions. |
3.04 pts Acceptable The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic, and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions. |
2.4 pts Needs Improvement The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic, measure and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. |
0 pts Unsatisfactory The goals lack support and nonspecific from gathered data, Outcome criteria are not specific, realistic, measurable, attainable, nor timed. Does not evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention. |
4 pts
This criterion is linked to a Learning OutcomeMultidisciplinary Client Outcome & Discharge Planning
Analysis of teamwork and collaborative cues; analysis of collaboration with discharge planning
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4 pts Proficient Clearly and accurately describes concerns related to multidisciplinary discharge planning. |
3.04 pts Acceptable Adequately describes concerns related to multidisciplinary discharge planning. |
2.4 pts Needs Improvement Vaguely describes concerns related to multidisciplinary discharge planning. |
0 pts Unsatisfactory Fails to describe concerns related to multidisciplinary discharge planning. |
4 pts
This criterion is linked to a Learning OutcomeTeaching assessment & client education
Responding and implementation; responding to identified client educational needs.
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8 pts Proficient Clearly and accurately identifies areas of instructional needs, learning preference, and learning barriers. Provided clear and concise client education that will aid in health promotion, health maintenance and self-care activities. |
6.08 pts Acceptable Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education that aids in health promotion, health maintenance and self-care activities. |
4.8 pts Needs Improvement Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education that will aid in health promotion, health maintenance and self-care activities. |
0 pts Unsatisfactory Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education that will aid in health promotion, health maintenance and self-care activities. |
8 pts
This criterion is linked to a Learning OutcomePertinent lab test & abnormal involuntary movement
Interpreting data for analyses of cues
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4 pts Proficient Clearly and accurately identifies pertinent laboratory tests with abnormal values and identifying trends related to a client’s disease process |
3.04 pts Acceptable Adequately identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
2.4 pts Needs Improvement Vaguely identifies pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
0 pts Unsatisfactory Fails to identify pertinent laboratory tests with abnormal values and identifying trends related to the client’s disease process. |
4 pts
This criterion is linked to a Learning OutcomeNursing clinical judgments
Interpreting data for prioritizing hypotheses; this criterion is linked to a clinical outcome: nursing clinical judgment.
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8 pts Proficient The 4 nursing clinical judgements are accurate and prioritized with clear etiology and data to support rationale. The clinical decision is consistent and presents correlation from the assessment data based on Maslow’s Hierarchy and Mental Status Examination. |
6.08 pts Acceptable The 4 nursing clinical Judgments are adequate and prioritized with sufficient etiology and data to support rational. The nursing clinical decision is adequate and presents correlation from assessment data based on Maslow’s Hierarchy and Mental Status Examination. |
4.8 pts Needs Improvement The 4 clinical judgments are vague and not prioritized with vague etiology and unclear correlation from the assessment data that may or may not be classified based on Maslow’s Hierarchy and Mental Status Examination. |
0 pts Unsatisfactory No clinical judgment is listed and or are based on Maslow’s Hierarchy and Mental Status Examination. |
8 pts
This criterion is linked to a Learning OutcomeNursing clinical goals
Evaluation of nursing clinical judgment; clinical thinking + clinical reasoning = clinical judgment
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8 pts Proficient Clearly and accurately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal clearly supports the clinical decisions and plan of care. The goals are easily measurable and realistic. |
6.08 pts Acceptable Adequately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic. |
4.8 pts Needs Improvement Vaguely establishes client’s outcome criteria and may or may not be achieved with nursing assistance. The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic and measurable. |
0 pts Unsatisfactory Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The goals lack support and nonspecific from gathered data, Outcome criteria are not realistic and not measurable. |
8 pts
This criterion is linked to a Learning OutcomeNursing interventions criteria & rationale
Interpret planning to generate solutions
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8 pts Proficient Clearly and accurately Identifies independent nursing interventions criteria with teaching supported by scientific rationale and evidence-based practice. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on nursing assessment and Erickson’s stages of development. |
6.08 pts Acceptable Adequately Identifies nursing interventions with adequate teaching. Scientific rationale is adequately supported by evidence-based practice. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation based on nursing assessment and Erickson’s stages of development. |
4.8 pts Needs Improvement Vaguely Identifies nursing interventions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis based on nursing assessment and Erickson’s stages of development. |
0 pts Unsatisfactory Fails to identify interventions and teaching. Lack Scientific rationale and is not supported by evidence-based practice. Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does do not focus on client goals and/or the stated health deviation based on nursing assessment and Erickson’s stages of development. |
8 pts
This criterion is linked to a Learning OutcomeEvaluation
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8 pts Proficient Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions and measure’s goal completion. Modifies, revises, and recommends alternative intervention. |
6.08 pts Acceptable Adequately identifies criteria for evaluation. Adequately determines effectiveness of nursing interventions and measure’s goal completion with appropriate modification and revisions to the treatment plan. |
4.8 pts Needs Improvement Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. Evaluation vaguely supports if goal is met or not met with inaccurate revisions to the treatment plan. |
0 pts Unsatisfactory Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan. |
8 pts
This criterion is linked to a Learning OutcomeMedications
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8 pts Proficient Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels, and nursing considerations relevant to the client. |
6.08 pts Acceptable Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels, and nursing considerations relevant to the client. |
4.8 pts Needs Improvement Vaguely identifies components of the medication list. Lack description of mechanism of action, purpose, range side effects, interactions, levels, and nursing considerations relevant to the client. |
0 pts Unsatisfactory Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels, and nursing considerations relevant to the client. |
8 pts
This criterion is linked to a Learning OutcomeGeneral Organization
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4 pts Proficient Accurate APA format, appropriate citations, and references, No spelling or grammar errors. |
3.04 pts Acceptable Adequate APA format. Minimal citations and references are appropriate. Few spellings or grammar errors. |
2.4 pts Needs Improvement Numerous APA format errors, Inaccurate citations, and references. Few spelling and grammar errors. |
0 pts Unsatisfactory Fails to utilize APA format. No citations or references included numerous spelling and grammar errors. |
4 pts
Total Points: 100
