Care plan and concept map
Need assistance with creating a careplan and concept map. All details are attached with specific details.
2 years ago
30
ConceptMapDirectionsMAT.docx
REVISED8.7.2017CarePlanGradingRubric1.docx
- CarePlanandConceptMap.doc
ConceptMapDirectionsMAT.docx
Concept Map Directions
You will submit one data packet that contains two concept maps by the due date on Blackboard. You will have to collect data at clinicals to complete your concept map. There are tons of resources on the internet on concept mapping if you need extra assistance. You will receive a copy of a sample concept map for reference and the format it should be done.
One data packet; 2 nursing diagnosis for the maps (1 per map), information sheet will be all inclusive of medical history, present/current history, treatments. (Make sure to go in-depth for the history – years for surgeries, etc.).
1. Use the diagnosis for admission to the hospital and if there is more than one include all.
2. List ALL medical history (HTN, CAD, DM, CHF, Asthma, Pneumonia, etc) and treatments.
3. Take the top two problems and create the NANDA nursing diagnoses (2). You may use Taber’s or any scholarly source; be thorough. (Do not use Taber’s online)
4. Decide what your overall statement will be for your goals. This will be your NOC statement; needs to simply state your goals in one sentence.
5. Using your NOC, create three (3) goals for each diagnosis; they must be SMART (Specific, Measurable, Attainable, Realistic, Timely). 2 short term and 1 long term goal. Use your nursing diagnosis book.
6. Develop the NIC statement and interventions (3) for each goal ; this is what the nurse will do to assist the client in meeting the goals. Use your nursing diagnosis book.
7. Pathophysiologic rationale for each intervention (3) ; explain why systemically. Rationales should include citations!
8. Evaluate each goal (3) ; 2 short term and 1 long term. Annotate whether goal was met or not, how, and why. Should it be continued or discontinued? What else will you do if the goal is not met?
In summary
You will have one complete data packet. This data packet will begin with a cover page that lists your name, course number, due date, etc.
Everything MUST be in APA 7th edition format, especially reference page – use APA Guide in Blackboard Resources or go to Writing Lab.
· One (main) medical problem, use in both maps
· A nursing diagnosis (per map, so 2 total)
· Nursing goals (should have two short term goals and one long term goal)
· Assessment on nurses note (include vs., pain, head to toe, FHT, blood sugar…) Make a note in map to see nurses note for full assessment, but include key information from assessment in map.
· Interventions (what you will do to help your patient meet the goal - Action)
· Rationale (why is this important; physiologic, etc.) Must be cited.
· Evaluation (This is in short statement; stating whether the client met the goal or need to modify it or discontinue it and why/how it was met or not met)
· Medications – Just list name, dosage and frequency of each med
· Laboratory – List names of labs/tests and results.
See the MAT concept map template and insert your information as you go. Be sure to remove all red text.
REVISED8.7.2017CarePlanGradingRubric1.docx
Care Plan Grading Rubric
Student: Date:
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Criteria |
Criteria Met/Not Met 0=Not Met 1=Met |
Comments
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1. ASSESSMENT |
8 criteria |
SLO: Inter / Intra-disciplinary Collaboration SLO: Technology Integration
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1. Introduction: summary of client profile and recent history leading up to current admission |
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2. Pathophysiology of identified medical dx: summary complete, individualized to client (with references) |
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3. Medical treatment: medications, treatments: related to client's signs/symptoms; concisely summarized (with references) |
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4. Laboratory Findings (with references & rationales) |
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5. Medication List (with references & rationales) |
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6. Head to toe assessment summary: accurate, concise, complete; appropriate delineation of subjective and objective |
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7. Clustering: of assessment data appropriate to nursing dx |
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8. Past Medical History |
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2. NURSING DIAGNOSIS STATEMENT
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4 criteria |
SLO: Judgment / Reasoning
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9. Problem statement/nursing diagnosis: NANDA |
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10. Etiology/"as related to": |
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11. Signs/symptoms /defining characteristics: "as evidenced by" |
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12. Appropriate for and individualized to the client |
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3. GOALS / OUTCOMES ( one LT; two ST ) |
5 criteria |
SLO: Judgment / Reasoning |
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13. Behavioral, measurable/time frame for achievement |
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14. Realistic, attainable |
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15. Specific |
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16. Individualized to client's needs |
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17. Prioritized (Maslow’s / Developmental Theory) |
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4. INTERVENTIONS |
5 criteria |
SLO: Judgment / Reasoning |
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18. Related to the goal/outcome |
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19. Individualized and specific |
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20. Behavioral, including frequency |
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21. Prioritized in appropriate order of performance |
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22. Include at least two independent per ND; include assessment, teaching, treatment |
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5. RATIONALES |
3 criteria |
SLO: Judgment / Reasoning |
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23. Specific to goals/interventions stated |
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24. Rationales accurate and reflective of scientific basis of nursing practice (utilize nursing texts) |
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25. Referenced with page number’s |
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6. IMPLEMENTATION |
2 criteria |
SLO: Judgment / Reasoning |
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26. Nursing care clearly stated and related to specific goals |
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27. Client's response to care provided clearly stated |
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7. EVALUATION |
2 criteria |
SLO: Judgment / Reasoning |
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28. Each ST goal evaluated: met, not met, partially met; evidence provided |
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29. Care plan status: continue, revise, discontinue |
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8. PRESENTATION |
3 criteria |
SLO: Professionalism
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30. Grammar, spelling, and neatness |
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31. Appropriate use of medical terminology |
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32. Reference page in APA format |
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TOTAL Criteria |
32 criteria |
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Grading example: Number of points awarded (criteria met)/32 (total number of criteria) X 100= Percentage
Example: 25 criteria met/32 total criteria X 100= 78 %
Passing is greater than 76%
Care plans should reflect each semester’s client population and thereby also reflect the increasing skill level of the student.
Care plans are expected to be all inclusive and complete. Students will be given the opportunity to re-submit care plans that are not complete.
No points are awarded for unmet criteria.
Care Plan Grading Rubric rev. 8.2017 bjk Page 1
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