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2021 Maternal Patient Care Plan Assignment Rubric INSTRUCTIONS

5 POINTS

4 POINTS

3 POINTS

2 POINTS

1 POINT

O POINTS

SCORE

PATIENT INFORMATION AND HEALTH ASSESSMENT :

-INCLUDES: Patient Demographics, Reproductive History, Physical, Psychological, Psychosocial, Cultural/Spiritual, Growth and Development, assessments and interventions

-Lab Work/Diagnostic Data

Patient demographics, health assessments, reproductive history, physical, pyschological, psycosocial, cultural/spiritual, growth and development assessments and interventions complete. Lab work and diagnostic data complete

Minor omissions from patient demographics, reproductive history, physical, psychological, psychosocial, cultural/spiritual, G&D assessments and interventions. Most of lab data complete.maternal.

50% of information required for this category is in place. Items are missing and/or documented information is inaccurate or irrelevant.

75% of patient demographics, health assessment and interventions are missing and/or inaccurate

Data collection and assessments reflects that no effort was applied to this section of the assignment resulting in a flawed plan of care.

2 POINTS

1 POINT

0 POINTS

SCORE

PHYSIOLOGICAL/ PATHOPHYSIOLOGICAL DISCUSSION;

-INCLUDES “signs and symptoms” ; APA references cited

Physiology discussion completed; relevant to specific patient; given with accurate details related to client’s status in the childbirth process; includes a pathophysiology discussion if relevant to patients current health APA references noted.

Physiology discussion completed providing minimal detail. Pathophysiology discussion omitted when relevant to patient's current health status. APA references omitted.

Physiology discussion is omitted or not relevant to patient's current status in childbirth process. Pathophysiology discussion omitted when it should have been included on care plan. APA references omitted.

3 POINTS

2 POINTS

1 POINT

O POINTS

SAFETY ASSESSMENT, DISCHARE PLAN, TEACHING NEED:

- Include expected and actual needs

- Discharge plan: briefly state when and with whom

-Identify the teaching needs for this mother and/or family (list in bullet points )

Maternal safety needs addressed. Discharge plan addressed: when/with whom. Discharge teaching needs for maternal self-care and newborn care listed in bullet points

Maternal safety needs addressed. Discharge plan addressed. Discharge teaching needs incomplete for maternal self-care and newborn care.

Nominal mention of maternal safety needs, Discharge plan not addressed. Discharge teaching needs missing or contain limited information

Safety assessment not addressed. Discharge plan not noted. Incomplete teaching needs

PHARMACOLOGY:

Complete accurate description of current meds, including purpose for this patient, side effects, and all other data listed in chart

List all MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug

Most of the MAR meds with description, side effects and nursing considerations specific to patient and why patient is receiving drug

List some MAR meds but does not include relevant side effects and nursing considerations specific to patient

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

NURSING DIAGNOSIS (INCLUDE 3 NURSING DIAGNOSIS):

-Risk for diagnosis are in lower priority than active nursing diagnosis

Nursing diagnosis table is complete with 3 diagnosis. Appropriate for patient; priority levels included. NANDA approved. Diagnosis also includes all parts and information

At least 2 of 3 nursing diagnosis are appropriate for patient/priority level included. NANDA approved. Does not include all parts or info is listed in wrong part of diagnosis

Not all nursing diagnosis appropriate. Priority level is incorrect or not included. May also not be NANDA approved and may not include all parts

Diagnosis selected reflects that no effort to interpret info was applied resulting in a flawed plan of care. NANDA format is not complete or used correctly

3 POINTS

2 POINTS

I POINT

0 POINTS

NSG DIAGNOSIS #1: ASSESSMENT:

Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis

Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx

3 POINTS

Includes all pertinent data related to nursing Dx., but also includes data not relate to Dx

2 POINTS

Doesn’t include all pertinent related data to nursing Dx. May include data not relating to Dx

1 POINT

Not all relevant subjective & objective data is collected. There is an absence of the use of inquiry to collect info relevant to the individual's disease & circumstances.

0 POINTS

NSG DIAGNOSI #1:

OUTCOMES:

Outcomes should be specific to the patient Dx., The outcome statement should also contain the following 4 criteria: measurable, attainable, realistic, and timed. All criteria should be present to be a specific patient expected outcome

Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria. Should have 2 outcomes.

Outcomes statement is specific to pt. Dx. and it only contains two of the 4 measurable criteria

Outcomes statement is not specific to pt. Dx. and it only contains 1 of the 4 measurable criteria

Some of the outcome criteria identified to achieve goals will lead to the resolution or control of the related factors and purely based on coincidence

NSG DIAGNOSIS #1:

INTERVENTIONS AND RATIONALES:

Include interventions or nursing actions that directly relate to the patient's goal; are specific in action, frequency and contain rationale. The number of interventions should be appropriate to help patient/family meet their goal

Interventions portion contains adequate # of interventions to help pt./family meet outcome, and interventions are specific in action and frequency, and are listed with rationales

Interventions portion contains adequate # of interventions to help pt./family meet outcome, but may not be specific, labeled or listed with rationales

Intervention portion doesn’t include adequate # of interventions to help pt./family meet outcome. May also not be specific, labeled or listed with rationales

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

NSG DIAGNOSIS #1:

EVALUATION:

Includes all data that is listed as criteria in outcome statement. Based on this data, outcome is determined to be met, partially met, or not met. If outcome was not met or partially met, plan of care is revised or continued and a new evaluation date/time is set

Evaluation portion does contain data that is listed as criteria in outcome statement. Does describe outcome as met, partially met or not met. If outcome partially met or not met, includes revision and or a new evaluation date time

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

Evaluation portion does not contain data that is listed as criteria in outcome statement. May also not describe outcome as met, partially met or not met. May also not include revision or new evaluation date/time

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

3 POINTS

2 POINTS

I POINT

0 POINTS

NSG DIAGNOSIS #2: ASSESSMENT:

Appropriate for chosen diagnosis. Includes objective & subjective historical data that support actual or risk for nursing diagnosis

Includes all pertinent data related to nursing Dx., and does not include data that is not related to Dx

Includes all pertinent data related to nursing Dx., but also includes data not relate to Dx

Doesn’t include all pertinent related data to nursing Dx. May include data not relating to Dx

Not all relevant subjective & objective data is collected. There is an absence of the use of inquiry to collect info relevant to the individual's disease & circumstances.

NSG DIAGNOSI #2:

OUTCOMES:

Outcomes statement is specific to pt. Dx. and contains all 4 measurable criteria. Should have 2 outcomes.

Outcomes statement is specific to pt. Dx. and it only contains two of the 4 measurable criteria

Outcomes statement is not specific to pt. Dx. and it only contains 1 of the 4 measurable criteria

Some of the outcome criteria identified to achieve goals will lead to the resolution or control of the related factors and purely based on coincidence

NSG DIAGNOSIS #2:

INTERVENTIONS AND RATIONALES:

Interventions portion contains adequate # of interventions to help pt./family meet outcome, and interventions are specific in action and frequency, and are listed with rationales

Interventions portion contains adequate # of interventions to help pt./family meet outcome, but may not be specific, labeled or listed with rationales

Intervention portion doesn’t include adequate # of interventions to help pt./family meet outcome. May also not be specific, labeled or listed with rationales

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

NSG DIAGNOSIS #2:

EVALUATION:

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

TOTAL SCORE: /40