Fill in the acute care documentation. information is in the I am a nurse folder. each section needs APA citation. and for nursing diagnosis please use internet (nurseslabs.com

Grading Rubric: Comprehensive Nursing Care Plan

Total points= 64 (Must score at least 51 points to pass)

Care Plan Sections

INITIAL

EMERGING

DEVELOPED

HIGHLY DEVELOPED

Points

Assessment Part I: Patient History

(4 pts)

Demonstrates 1 of 4 criteria listed in “highly developed” column.

Worth 1 point

Demonstrates 2 of 4 criteria listed in “highly developed” column

Worth 2 points.

Demonstrates 3 of 4 criteria listed in “highly developed” column.

Worth 3 points

Patient History section of care plan reflects criteria below

1. History of present illness and hospital course thoroughly described

2. Any data that is not collected is adequately explained.

3. Data collected through the use of inquiry flawlessly, applying knowledge about the individual's disease and the patient's circumstances.

4. All past medical history diagnosis and related home medication informaion are recorded accurately

Worth 4 points

Assessment Part II: Beginning of Pt. Care

(6 pts)

Demonstrates < 3 of 6 criteria listed in “highly developed” column.

Worth 3 points

Demonstrates 3 of 6 criteria listed in “highly developed” column.

Worth 4 points

Demonstrates 5 of 6 criteria listed in “highly developed” column.

Worth 5 points

Assessment section of care plan reflects criteria below:

1. All subjective/objective data are collected and appropriate terminology used

2. Any data that is not collected is adequately explained.

3. Data collected through the use of inquiry flawlessly, applying knowledge about the individual's disease and the patient's circumstances.

4. Physical assessment is complete covering all systems and data are accurate

5. Psychosocial and spiritual assessment are included

6. Clinical significance for relevant data are described

Worth 6 points

Growth and Development

(6 pts)

Demonstrates < 3 of 6 criteria listed in “highly developed” column.

Worth 3 points

Demonstrates 3 of 6 criteria listed in “highly developed” column.

Worth 4 points

Demonstrates 5 of 6 criteria listed in “highly developed” column.

Worth 5 points

Growth and Development section of care plan reflects criteria below

1. The patient’s expected developmental level using Erikson and Piaget theorie is correctly indicated and supported with specific criteria

2. The patient’s expected physical developmental level is described and supported with specific criteria

3. The patient is compared to the expectation and examples are given to determine if the patient is at or below the expected developmental level.

4. Specific examples of the patients actual developmental level for Erkison and Piaget theories are provided.

5. Specific examples of the patients actual Physical developmental achievements are provided

6. Discussion is provided to explain differences between expected and actual findings.

Worth 6 points

Diagnostic Tests

(4 pts)

Demonstrates 1 of 5 criteria listed in “highly developed” column.

Worth 1 point

Demonstrates 2 of 4 criteria listed in “highly developed” column

Worth 2 points.

Demonstrates 3 of 4 criteria listed in “highly developed” column.

Worth 3 points

Diagnostics section of care plan reflects criteria below:

1. All pertinent diagnostic test results related to patient history, current diagnosis and plan of care are recorded.

2. Appropriate clinical significance is described accurately.

3. Data recorded helps to confirm, clarify and direct patient care

4. Data recorded is incorporated into the plan of care.

Worth 4 points

Lab Tests

(4 pts)

Demonstrates 1 of 5 criteria listed in “highly developed” column.

Worth 1 point

Demonstrates 2 of 4 criteria listed in “highly developed” column

Worth 2 points.

Demonstrates 3 of 4 criteria listed in “highly developed” column.

Worth 3 points

Lab section of care plan reflects criteria below :

1. All pertinent lab data results related to patient history, current diagnosis and plan of care are recorded.

2. Appropriate clinical significance is described accurately.

3. Data recorded helps to confirm, clarify and direct patient care

4. Data recorded is incorporated into the plan of care.

Worth 4 points

Medications

(8 pts) each criteria counts as double points

Demonstrates 1 of 4 criteria listed in “highly developed” column.

Worth 2 points

Demonstrates 2 of 4 criteria listed in “highly developed” column.

Worth 4 points

Demonstrates 3 of 4 criteria listed in “highly developed” column.

Worth 6 points

Medications section of care plan reflects criteria below :

1. All current medications are included

2. Information included is pertinent to patient

3. Student identifies potential problems and teaching needs individualized to the patient being cared for that is incorporated into the plan of care.

4. All pertinent nursing actions related to the medication are indicated.

Worth 8 points

Clinical Reasoning & Nursing Prioritization

(10 pts) each criteria counts as double points

Demonstrates < 3 of 5 criteria listed in “highly developed” column.

Worth 5 points

Demonstrates 3 of 5 criteria listed in “highly developed” column.

Worth 7 points

Demonstrates 4 of 5 criteria listed in “highly developed” column.

Worth 8 points

CR & NP section of care plan reflects criteria below:

Clinical Reasoning:

1. Medical diagnosis or syndrome is thoroughly described

2. Pathophysiology of the disease accurately described

3. Clinical manifestations, treatment, and usual prognosis accurately described

Nursing Prioritization:

4. Individual evaluation of 2 nursing diagnosis and appropriate ranking in priority order that best reflects the coordination of care.

5. Include at least one physiological and one psychosocial nursing diagnosis.

Worth 10 points

Nursing Care Plan

(22 point) each criteria counts 2 points.

Demonstrates </= 6 of 11 criteria listed in “highly developed” column.

*Worth 12 points

Demonstrates -7-8 of 11 criteria listed in “highly developed” column.

*Worth 15 points

Demonstrates 9-10 of 11 criteria listed in “highly developed” column.

*Worth 18 points

Nursing Care Plan section reflects the criteria below Two nursing diagnoses are evaluated individually and are ranked in priority order to best reflect the coordination of care appropriate to the patient

1. At least one of the diagnoses is an actual diagnosis rather than an at-risk diagnosis

2. Nursing diagnoses selected reflect the accurate interpretation of the subjective and objective data analyzed.

3. All nursing diagnoses use NANDA terminology and formatting.

Goals:

4. Measurable criteria are identified and contain verb and time element.

5. The criteria identified are individualized to the patient and will lead to the control of the related factors that contribute to the nursing diagnosis.

6. A short term and long term goal is listed for each NANDA Diagnosis.

7. Goals are written in a SMART format.

Interventions

8. Specific interventions can easily be linked to specific outcomes.

9. The interventions are realistic and appropriate to the patient's current status.

10. Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.

Evaluation –

11. Appropriate subjective and objective data is selected, through review of the interventions related to ongoing assessment that reflects adequate analysis

Worth 22 points

PRE-CLINICAL: Clinical Reasoning Questions to Promote Nurse Thinking

(Formulate and reflect before and after report, but BEFORE seeing patient the first time)

1. What is the primary problem and the underlying cause /pathophysiology of this problem?

2. What clinical data from the chart is RELEVANT that needs to be trended because it is clinically significant?

3. What nursing priority will guide your plan of care?

4. What nursing interventions will you initiate based on this priority and what are the desired outcomes?

5. What body system(s) will you focus on based on your patient’s primary problem or nursing care priority?

6. What is the worst possible/most likely complication(s) to anticipate today with your patient?

7. What nursing assessments will you need to initiate to identify this complication if it develops?

History of Present Problem:

Personal/Social History:

PMH:

What Came FIRST:

What Then Followed

Past Medical & Surgical History, Chronic Conditions:

Home Meds: Name, dose, frequency

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