Clinical for Community and Public Health Nursing

Student:

Date:

9/26/2021

Instructor

Course

NUR4200C

Patient Initial

AD

Unit/ Room#

DOB

07/01/2021

Code Status:

Full Code

Height/Weight

Allergies

No know

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

Criteria

4 Exceeds Expectations

3 Meets Expectations

2 Approaching Expectations

1-0

Does Not Meet Expectations

Score

History of Present

Illness

HPI explained in detail with accurate and in- depth understanding of chief complaint and supported by evidence based citations

HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations

HPI explained in limited detail with marginal

understanding of chief complaint and no support from evidence based citations

HPI details limited with poor understanding of chief complaint and no evidence based citations to support

X2

Physical Assessment, & Diagnostic tests/ procedures

Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations

Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations

Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations

Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations

X2

Past Medical &

Surgical History, Pathophysiology

Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and

supported by evidence based citations

Past medical/surgical; history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations

Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations

No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence

X2

Erikson’s

Developmental Stages

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations

Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations

Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations

X2

Socioeconomic/ Psychosocial Assessment

Describes socioeconomic and cultural background in complete detail with references

Identifies 3 psychosocial concerns

Describes socioeconomic and cultural background in some detail with references

Identifies 2 psychosocial concerns

Describes socioeconomic and cultural background in vague detail without references

Identifies 1 psychosocial concern.

Describes socioeconomic and cultural background

with no detail without references

Identifies no psychosocial concerns

X1

Interprofessional

Consults & Discharge

Referrals

Lists 3 or more appropriate collaborative issues/concerns

Rationale demonstrates excellent understanding of consults and interventions

Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory

understanding of consults and

interventions

Lists 1 appropriate collaborative issue/concern

Rationale demonstrates vague understanding of consults and interventions

Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory

understanding of consults and

interventions

X2

Potential Health

Deviations

Identifies TWO prioritized risk factors in proper format

Writes 3 independent nursing interventions

Identifies 1 prioritized risk factor in proper format

Writes 2 independent nursing interventions

Identifies 2 prioritized risk factors but not in proper format

Writes 1 independent pertinent nursing intervention

Does not identify prioritized risk factors

Writes 0-1 independent nursing intervention not pertinent to the diagnosis

X3

Priority

Nursing Diagnosis

TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis

One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis

Written incorrectly with sufficient data to support diagnosis, not a priority

Written incorrectly, not in correct format, or without sufficient data to support diagnosis

X4

Planning/Goals &

Evaluation

Goal is measureable, realistic, related to the problem;

Data supports if goal is met, not met with appropriate revisions

Goal is not measureable, realistic, related to the problem;

Data somewhat supports if goal is met, not met with appropriate revisions

Goal is not measureable, not realistic, related to the problem;

Data vaguely supports if goal is met, not met with inappropriate revisions

Goal is not measureable, not realistic, not related to the problem;

Data does not support if goal is met, not met with inappropriate revisions

X2

Implementation and

Rationale

Identifies 4 independent interventions with teaching;

Each is supported with scientific rationale using textbook or evidence based citations

Identifies 3 independent interventions with teaching;

Scientific rationale is supported with scientific rationale using textbook or evidence based citations

Identifies 2 independent interventions with teaching;

Scientific rationale is vaguely relevant & not supported from textbook

Identifies 1 independent interventions with teaching;

Scientific rationale is not relevant & not supported from textbook

X2

Medications

Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug

Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug

Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug

Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient

X2

General Organization

Accurate APA format, Appropriate citations & references, No spelling or grammar errors

1-2 APA format errors, Some citations, references are appropriate, Minimal spelling or grammar errors

Many APA format errors, Inappropriate citations or references,

Many spelling or

grammar errors

No APA formatting, No citations or references included, Many spelling or grammar errors

X1

Total

/100 %