Care plan and Concept Map for Medical-Surgical (Nursing)

Criteria

Satisfactory

(10/5 pts)

Needs Improvement

(8/3 pts)

Unsatisfactory

(6/2 pts)

Medical Diagnosis/Etiology

(10 pts)

Collects and appropriately Identifies primary medical diagnosis AND past medical history of the patient

Collects and identifies either the primary diagnosis or the past medical history

No primary diagnosis identified, no past medical history collected

Pathophysiology

(10 pts)

Explains the processes within the body that result in the signs and symptoms of a disease with appropriate references

Partially or incompletely explains the process in the body that result in the signs and symptoms of a disease or inappropriate/no references provided

NO explanation of the disease process that results in the signs and symptoms of a disease and/or no references provided

Risk factors

(5 pts)

Identify the risk factors of the diagnosis and specify which risk factors relate to their patient

Demonstrated the ability to partially collect and/or partially record appropriate and accurate client data OR Does not relate risk factors to the client

Does not identify clinical manifestations and does not compare to their patient’s manifestations AND Does not relate to the client

Clinical Manifestations

(10 pts)

Identify clinical manifestations of the primary diagnosis and compare to their patient manifestations

Identifies partial clinical manifestation of the primary diagnosis or Does not compare to patient manifestations

Does not identify clinical manifestations and does not compare to their patient’s manifestations

AND

Does not relate to the client

Diagnostic Tests

(5 pts)

Identify and explain pertinent diagnostic test with pre and post care (May use ATI diagnostic test modules)

Identifies and/or partially explains pertinent diagnostic test with partial list of pre and post-care

Does not identify or explain pertinent diagnostic tests nor provide a list of pre- and post-care

Treatment (non Medication)

(10 pts)

Identify and explain treatment modalities and related patient care (not medications)

Identifies, but does NOT explain treatment modalities and related patient care

Does not identify treatment modalities related to the patient’s care

Drug therapy

(10 pts)

List medications on concept map and formulate “DRUG CARDS” for the prescribed medications

Partial or no medication list provided or

Partial/incomplete drug cards provided for listed medications

NO medication cards provided and no medication list provided

Nursing Diagnosis

(10 pts)

Develops an appropriate 3 part nursing diagnosis plan of care utilizing the nursing process accurately

Develops a 2-part nursing diagnosis or utilizing the nursing process partially inaccurate.

Develops a plan of care utilizing the nursing process inaccurately or does not utilize multipart nursing diagnosis

Expected Outcome (Goals)

(10 pts)

Develops appropriate goals for the client, both short and long term

Develops long or short term goals or utilizes partially inaccurate/unrealistic goals

Does not develop appropriate client goals or goals are not related to the patient

Nursing Interventions

(10 pts)

List 5 appropriate action orientated nursing interventions for the client related to established goals

Lists some appropriate goals or partially action-oriented goals for the client or interventions not related to the established goals

Interventions not action oriented to client and do not related to the established care goals

Evaluation/Patient Response Interventions

(5 pts)

Evaluation and progress of established care plan identified and discussed

Evaluation identified as met/not met/in-progress

Evaluation of care plan noted in simple language with no discussion

No evaluation of interventions or care plan provided

References in APA format (7th edition)

(5pts)

All in-text citations and document references formatted correctly

Some in-text and/or document references are cited appropriately according to APA formatting

Reference and in-text citations not provided or in-text and/or document references are not cited appropriately according to APA formatting

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