URS_210L-AB - NURSING CARE PLAN RUBRIC
URS_210L-AB - NURSING CARE PLAN RUBRIC
NURS_210L-AB - NURSING CARE PLAN RUBRIC
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeHistory of Present<br>Illness 8pts
Meets Expectations
HPI explained in detail with accurate and in- depth understanding of chief complaint and supported by evidence based citations 6.08pts
Mostly Meets Expectations
HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations 4pts
Approaches Expectations
HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations 2pts
Does Not Meet Expectations
HPI details limited with poor understanding of chief complaint and no evidence based citations to support
8pts
This criterion is linked to a Learning OutcomePhysical Assessment, & Diagnostic tests/ procedures 8pts
Meets Expectations
Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations 6.08pts
Mostly Meets Expectations
Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations 4pts
Approaches Expectations
Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citation 2pts
Does Not Meet Expectations
Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations
8pts
This criterion is linked to a Learning OutcomePast Medical &<br>Surgical History, Pathophysiology 8pts
Meets Expectations
Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the clients history and symptoms and supported by evidence based citations 6.08pts
Mostly Meets Expectations
Past medical/surgical; history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the clients history and symptoms. supported by evidence based citations 4pts
Approaches Expectations
Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the clients history and symptoms or not supported by evidence based citations 2pts
Does Not Meet Expectations
No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the clients history and symptoms without evidence
8pts
This criterion is linked to a Learning OutcomeEriksons<br>Developmental Stages 8pts
Meets Expectations
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations 6.08pts
Mostly Meets Expectations
Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations 4pts
Approaches Expectations
Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations 2pts
Does Not Meet Expectations
Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations
8pts
This criterion is linked to a Learning OutcomeSocioeconomic/ Psychosocial Assessment 4pts
Meets Expectations
Describes socioeconomic and cultural background in complete detail with references. Identifies 3 psychosocial concerns 3.04pts
Mostly Meets Expectations
Describes socioeconomic and cultural background in some detail with references. Identifies 2 psychosocial concerns 2pts
Approaches Expectations
Describes socioeconomic and cultural background in vague detail without references. Identifies 1 psychosocial concern. 1pts
Does Not Meet Expectations
Describes socioeconomic and cultural background with no detail without references. Identifies no psychosocial concerns
4pts
This criterion is linked to a Learning OutcomeInterprofessional<br>Consults & Discharge<br>Referrals 8pts
Meets Expectations
Lists 3 or more appropriate collaborative issues/concerns Rationale demonstrates excellent understanding of consults and interventions 6.08pts
Mostly Meets Expectations
Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory understanding of consults and interventions 4pts
Approaches Expectations
Lists 1 appropriate collaborative issue/concern Rationale demonstrates vague understanding of consults and interventions 2pts
Does Not Meet Expectations
Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory understanding of consults and interventions
8pts
This criterion is linked to a Learning OutcomePotential Health<br>Deviations 12pts
Meets Expectations
Identifies TWO prioritized risk factors in proper format. Writes 3 independent nursing interventions 9.12pts
Mostly Meets Expectations
Identifies 1 prioritized risk factor in proper format. Writes 2 independent nursing interventions 6pts
Approaches Expectations
Identifies 2 prioritized risk factors but not in proper format. Writes 1 independent pertinent nursing intervention 3pts
Does Not Meet Expectations
Does not identify prioritized risk factors. Writes 0-1 independent nursing intervention not pertinent to the diagnosis
12pts
This criterion is linked to a Learning OutcomePriority<br>Nursing Diagnosis 16pts
Meets Expectations
TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis 12.16pts
Mostly Meets Expectations
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 8pts
Approaches Expectations
Written incorrectly with sufficient data to support diagnosis, not a priority 4pts
Does Not Meet Expectations
Written incorrectly, not in correct format, or without sufficient data to support diagnosis
16pts
This criterion is linked to a Learning OutcomePlanning/Goals & Evaluation 8pts
Meets Expectations
Goal is measureable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions 6.08pts
Mostly Meets Expectations
Goal is not measureable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions 4pts
Approaches Expectations
Goal is not measureable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions 2pts
Does Not Meet Expectations
Goal is not measureable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions
8pts
This criterion is linked to a Learning OutcomeImplementation and<br>Rationale 8pts
Meets Expectations
Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using textbook or evidence based citations 6.08pts
Mostly Meets Expectations
Identifies 3 independent interventions with teaching; Scientific rationale is supported with scientific rationale using textbook or evidence based citations 4pts
Approaches Expectations
Identifies 2 independent interventions with teaching; Scientific rationale is vaguely relevant & not supported from textbook 2pts
Does Not Meet Expectations
Identifies 1 independent interventions with teaching; Scientific rationale is not relevant & not supported from textbook
8pts
This criterion is linked to a Learning OutcomeMedications8pts
Meets Expectations
Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug 6.08pts
Mostly Meets Expectations
Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug 4pts
Approaches Expectations
Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug 2pts
Does Not Meet Expectations
Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient
8pts
This criterion is linked to a Learning OutcomeGeneral Organization 4pts
Meets Expectations
Accurate APA format, Appropriate citations & references, No spelling or grammar errors 3.04pts
Mostly Meets Expectations
1-2 APA format errors, Some citations, references are appropriate, Minimal spelling or grammar errors 2pts
Approaches Expectations
Many APA format errors, Inappropriate citations or references, Many spelling or grammar errors 1pts
Does Not Meet Expectations
No APA formatting, No citations or references included, Many spelling or grammar errors
4pts
Total Points:100
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date
19050161925Patient Information
(1)
Patient Initials: J.A
Age & Gender: 60 year old Male
Height/Weight: 56/ 154 l.b
Code Status: Full Code
Living Will/ DPOA: Wife is DPOA
00Patient Information
(1)
Patient Initials: J.A
Age & Gender: 60 year old Male
Height/Weight: 56/ 154 l.b
Code Status: Full Code
Living Will/ DPOA: Wife is DPOA
left2143125Chief Complaint
Ex: SUBJECTIVE (Abnormal - Bullet Points)
Pt. is complaining of abdominal pain 8/10, for more than 16 hours along with nausea and vomiting.
Admitting Diagnosis & Admission Date
Admitting Diagnosis : Abdominal Pain
Admission date 00Chief Complaint
Ex: SUBJECTIVE (Abnormal - Bullet Points)
Pt. is complaining of abdominal pain 8/10, for more than 16 hours along with nausea and vomiting.
Admitting Diagnosis & Admission Date
Admitting Diagnosis : Abdominal Pain
Admission date 2371725-296545History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED) (SEE RUBRIC REQUIREMENTS)
Medical History: (SEE RUBRIC REQUIREMENTS)PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
For each procedure identified, define & describe it; include year of procedure & cite source
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
00History of Present Illness (HPI)
WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED) (SEE RUBRIC REQUIREMENTS)
Medical History: (SEE RUBRIC REQUIREMENTS)PAST DIAGNOSED MEDICAL PROBLEMS
For each disease identified, define, it, describe pathophysiology, and cite source
Surgical History: (SEE RUBRIC REQUIREMENTS)
PAST DIAGNOSED SURGICAL PROBLEMS
For each procedure identified, define & describe it; include year of procedure & cite source
Social History:
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
190504265930Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation& Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH) (SEE RUBRIC REQUIREMENTS)
Economic Stability
Education
Social and Community Context
Health and Health Care
Neighborhood and Built Environment
00Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation& Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH) (SEE RUBRIC REQUIREMENTS)
Economic Stability
Education
Social and Community Context
Health and Health Care
Neighborhood and Built Environment
52959004265930Ericksons Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS)
00Ericksons Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)
(SEE RUBRIC REQUIREMENTS)
-152400105411005133975-361315TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for hospitalization) Support with Evidence Based CitationsPathophysiology of Primary Medical Dx (reason for
Ex: The primary pathophysiologic process in COPD is persistent but variable inflammation of the airways
(SEE RUBRIC REQUIREMENTS)
hospitalization)
TIME OUT!!! Student instructions:
(SEE RUBRIC REQUIREMENTS)
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Medical Management and Collaborative Plan
(From MD, PT, OT notes. etc.) *Consider past 24 48 hours
(SEE RUBRIC REQUIREMENTS)
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
MEDS
TREATMENT
00TIME OUT!!! Student instructions:
Pathophysiology of Primary Medical Dx (reason for hospitalization) Support with Evidence Based CitationsPathophysiology of Primary Medical Dx (reason for
Ex: The primary pathophysiologic process in COPD is persistent but variable inflammation of the airways
(SEE RUBRIC REQUIREMENTS)
hospitalization)
TIME OUT!!! Student instructions:
(SEE RUBRIC REQUIREMENTS)
Patient Education (In Pt.) for Referrals/ Discharge Planning
REFERRALS NEEDED/CASE Management
ASSESS LEARNING STYLE:
LEARNING PREFERENCE: WRITTEN, VIDEO, etc.
LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL
ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.
Medical Management and Collaborative Plan
(From MD, PT, OT notes. etc.) *Consider past 24 48 hours
(SEE RUBRIC REQUIREMENTS)
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE
EQUIPMENT
MEDS
TREATMENT
TIME OUT!!! Student instructions:
Include Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(With normal ranges), include dates and rationales supported with Evidence Based Citations
Include 2-3 nursing interventions for abnormal labs and for all diagnostic procedures
5181600317436600
Lab Tests or
Diagnostic Scan
Normal Ranges Admission Lab Values
Current Lab Values Explain Abnormal Labs R/T Your Pt & NI
(USE SEPARATE ATTACHED WORD DOC WHEN NEEDED)
-78105-4445100TIME OUT!!! Student instructions:
INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS
(Can add See attached Word Doc) 3400425-33274000142875-275590TIME OUT!!! Student instructions:
Medications & Allergies (2)
Medication Name
Include BOTH Generic AND Trade names for RX; include OTC, herbal (non-pharmacological items) Dose Route Freq.
NOTE: PRN alone Freq Indications
(PRN meds must include MD ordered Indication) Mechanism of Action Side Effects/
Adverse Reactions Nursing Considerations specific to this patient with citations
What cues will you observe for?
What will you monitor (labs, vitals, etc?)
00TIME OUT!!! Student instructions:
Medications & Allergies (2)
Medication Name
Include BOTH Generic AND Trade names for RX; include OTC, herbal (non-pharmacological items) Dose Route Freq.
NOTE: PRN alone Freq Indications
(PRN meds must include MD ordered Indication) Mechanism of Action Side Effects/
Adverse Reactions Nursing Considerations specific to this patient with citations
What cues will you observe for?
What will you monitor (labs, vitals, etc?)
ASSESSMENT/History of Present Illness /REVIEW OF SYTEMS
1238258191500
TIME OUT!!! Student instructions:
Physical Assessment Findings including presenting signs and symptoms that you will complete for this patient supported with Evidence Based Citations
-534670489839000
69723004100195MISC:
00MISC:
190504100195Integumentary (12)
00Integumentary (12)
46545504100195Psychosocial (14)
00Psychosocial (14)
23368004100195Endocrine (13)
00Endocrine (13)
left25400Vital Signs (4)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
00Vital Signs (4)
BP:
HR: (Rhythm)
RR:
Temp:
O2 (any supplemental)
Pain (0/10)
Ht (cm)
Wt. (Kg)
BMI:
740854523495Respiratory (7)
00Respiratory (7)
464058023495Cardiovascular (6)
00Cardiovascular (6)
232981523495Neurological (5)
00Neurological (5)
23368002071370GI/Hydration/Nutrition (9)
00GI/Hydration/Nutrition (9)
46545502071370GU (10)
00GU (10)
190502071370Musculoskeletal (8)
00Musculoskeletal (8)
69723002071370Rest/ Exercise (11)
00Rest/ Exercise (11)
TIME OUT!!! Student instructions:
To be sure your clinical judgement statements written below are accurate. You need to review the defining characteristics and related factors associated with and see how your patient data match. Do you have an accurate match or are additional data required, or does another cue from abnormal assessment findings need to be investigated?
-139485603573-10882093968432007111448318328200600559925942250042458772603658006975067152422633930111524226160282515291777200900772795Take Action
Sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.
0Take Action
Sorts the actions (based on their evaluation in various dimensions) and carries out the action(s) to address the hypothesis/hypotheses with highest priority first.
3629025791845Prioritize Hypotheses
Evaluates the probable client needs/concerns and problems generated previously in various dimensions and organize them into an ordered list where the priority hypotheses are on the top. (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent)
0Prioritize Hypotheses
Evaluates the probable client needs/concerns and problems generated previously in various dimensions and organize them into an ordered list where the priority hypotheses are on the top. (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent)
16668753982720Reflecting
0Reflecting
16668754334510Evaluate
0Evaluate
68580777875Recognize Cues
Obtain information from different sources (e.g., the environment, the pt., the family, another nurse, EHR) in different formats (e.g., visual observation, audio perception, lab results, text description, etc.).
0Recognize Cues
Obtain information from different sources (e.g., the environment, the pt., the family, another nurse, EHR) in different formats (e.g., visual observation, audio perception, lab results, text description, etc.).
-1873254735195Evaluation
Compare and contrast what happened with your plan of care against what was expected/anticipated (disease progression, unique client response) and decide whether additional clinical decisions are needed.
00Evaluation
Compare and contrast what happened with your plan of care against what was expected/anticipated (disease progression, unique client response) and decide whether additional clinical decisions are needed.
571492992120Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)
These should be written in a SMART format for patient goals.
For examples:
The patient will have decreased pain by verbalizing pain score 3/10 or below by the end of the shift.
The patient will maintain clear airway by effectively coughing by the end of the shift.
00Clinical Judgement (The expected/anticipated outcomes or SMART GOALS)
These should be written in a SMART format for patient goals.
For examples:
The patient will have decreased pain by verbalizing pain score 3/10 or below by the end of the shift.
The patient will maintain clear airway by effectively coughing by the end of the shift.
5350510789305Generate Solutions
Develops a list of actions to address the hypotheses. Give rationales for each solution.
00Generate Solutions
Develops a list of actions to address the hypotheses. Give rationales for each solution.
7204710122555Responding
Responding
1842770122555Interpreting
Interpreting
59690122555Observation
Observation
7204710436245Implement
Implement
5408930436245Planning
Planning
1842770436245Analysis
Analysis
55880436245Assessment
Assessment
1841500771525Analyze Cues
Interprets cues from their existing knowledge base and nursing perspective, evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organize cues in the mental representation of the scenario (e.g., organize cues in clusters), and then develops a group of probable client needs/concerns and problems
Analyze Cues
Interprets cues from their existing knowledge base and nursing perspective, evaluate cues in terms of relevancy, importance, and interrelationship among other cues, organize cues in the mental representation of the scenario (e.g., organize cues in clusters), and then develops a group of probable client needs/concerns and problems
References
Use APA format and hanging indents for all references.
If you have any questions, please consult the APA 7th Edition.
