College of Nursing

Nursing Care Plan

Student Course Date Instructor Patient Initial ______Height/Weight Age ______Unit Room# Code Status______Allergies______

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10

History of Present Illness including Admission Diagnosis Relevant Diagnostic Procedures/Results & Surgeries Relevant Physical Assessment Findings(normal & abnormal) (include dates, if not found state so)

Past Medical & Surgical History, Pertinent Lab tests/ Values (with normal ranges), Pathophysiology of medical diagnoses with dates and rationales (with APA citations)

Erikson’s Developmental Stage with Rationale Socioeconomic/Cultural/Spiritual Orientation (APA citation) & Psychosocial Considerations

Potential Health Deviations, Predisposing &Related Factors; Interprofessional Consults, Discharge Referrals, & Current Interventions to assess or prevent potential health deviations Orders(include diet, test, and treatments) with Rationale (“At Risk for…” nursing dx) (AT LEAST TWO) (with APA citations) Planning Prioritized Independent Evaluation (outcome/goal) and collaborative nursing Prioritized Goal Met, Nursing Diagnosis Measureable goal interventions; include Gordon’s Functional Rationale partially met, (at least 2) during your shift further assessment, Health Care Patterns (use APA citations) or not Met (at least 1 per intervention and & Explanation Nursing diagnosis) teaching (at least 4 per goal)

Current Medications Mechanism Nursing Medications Frequenc Dose(& range) of action Common side considerations (with APA Class/Purpose Route y If out of range, why? Onset of effects Specific to this citations action client College of Nursing

References College of Nursing

NURSING CARE PLAN RUBRIC NAME: COURSE: ______DATE: ______

CLIENT INITIALS: CLIENT DISEASE/DISORDER: ______

CRITERIA 10 8 5 3 POINTS 1.History of Present HPI explained in detail with HPI explained in some detail HPI explained in HPI details limited with poor Illness, Physical accurate and in-depth with moderate understanding limited detail understanding of chief complaint and Assessment, & understanding of chief of chief complaint and with marginal presenting signs/symptoms does not Diagnostic tests/ complaint and presenting presenting signs/symptoms understanding of support medical diagnosis, procedures signs/symptoms supported somewhat supported by chief complaint Identifies assessments parameters not by physical assessment; physical assessment; and presenting relevant to medical diagnoses, no identifies 5-6 key identifies 3-4 key assessments signs/symptoms references cited. assessments parameters parameters relevant to medical vaguely relevant to medical diagnosis with references. supported by diagnoses with APA physical references. assessment; identifies 1-2 key assessments parameters relevant to medical diagnosis, no references cited. 2. Past Medical & Past medical history Past medical history given Past medical No past medical history given without Surgical History, detailed with full with partial explanation of history given explanation; no preexisting medical Pathophysiology explanation of identified preexisting medical with minimal diagnosis identified or Pathophysiology for each diagnoses& explanation explanation of explanations inaccurate and not related diagnosis & accurate details accurate with some detail identified to the client’s history and symptoms with specific detail related related to the client’s history preexisting without references. to the client’s history and and symptoms. medical symptoms. References cited diagnoses & few APA references cited. details related to the client’s history and symptoms without references. 3. Erikson’s Identifies and defines Identifies and defines correct Identifies correct Identifies incorrect stage without Developmental Stages correct stage with examples stage with examples of stage without definition or inappropriate examples & Socioeconomic/ of meeting/not meeting meeting/not meeting tasks adequate given, no references. College of Nursing

Psychosocial tasks with APA references. with references. Describes definition or Describes socioeconomic and cultural Assessment Describes Socioeconomic Socioeconomic and cultural example of background with no detail without and cultural background in background in some detail. meeting/not references complete detail. Identifies 2 psychosocial meeting tasks Identifies no psychosocial concerns Identifies 3 psychosocial concerns without concerns references. Describes Socioeconomic and cultural background in vague detail without references Identifies 1 psychosocial concerns

CRITERIA 10 8 5 3 POINTS 4. Multidisciplinary Lists 3 or more appropriate Lists 2 appropriate Lists 1 Lists inappropriate collaborative Consults & Discharge collaborative collaborative issues/concerns appropriate issues/concerns Referrals issues/concerns Rationale demonstrates collaborative Rationale demonstrates unsatisfactory Rationale demonstrates satisfactory understanding of issue/concern understanding of interventions excellent understanding of interventions Rationale interventions demonstrates vague understanding of interventions 5. Potential Health Identifies TWO prioritized Identifies 1 prioritized risk Identifies 2 Does not identify prioritized risk factors Deviations risk factors according to factor according to NANDA prioritized risk or signs & symptoms not identified or NANDA format& identifies format& identifies 2 signs and factors but not not related to “at risk” diagnosis 3 signs and symptoms symptoms associated with the NANDA Writes 1 independent intervention not associated with the “at risk” “at risk” diagnosis format& pertinent diagnosis. Writes 2 independent nursing identifies 1 sign Writes 3 independent interventions or symptom nursing interventions associated with the “at risk” diagnosis Writes 1 independent pertinent intervention CRITERIA 5 3 2 1 POINTS 6. Gordon’s 11 Identifies 2 appropriate Identifies 1 appropriate health Identifies 2 Identify 1 inappropriate health care College of Nursing

Functional Health Care health care patterns care patterns inappropriate patterns Patterns health care patterns CRITERIA 10 8 5 3 POINTS 7. Priority NANDA TWO diagnoses written Written correctly without Written Written incorrectly without sufficient Nursing Diagnosis correctly per NANDA sufficient data to support incorrectly with data to support diagnosis format with proper etiology diagnosis sufficient data to &sufficient data to support support diagnosis diagnosis 8.Planning/Goals& Goal is measureable, Goal is not measureable, Goal is not Goal is not measureable, not realistic, Evaluation realistic, related to the realistic, related to the measureable, not not related to the problem; problem; problem; realistic, related Data does not support if goal is met, not Data supports if goal is met, Data somewhat supports if to the problem; met with not met with appropriate goal is met, not met with Data vaguely inappropriate revisions revisions appropriate revisions supports if goal is met, not met with inappropriate revisions 9. Implementation & Identifies 4 independent Identifies 3 independent Identifies 2 Identifies 1 independent interventions Rationale interventions with teaching; interventions with teaching; independent with teaching; Scientific rationale is not Scientific rationale is Scientific rationale is interventions relevant ¬ supported from textbook supported textbook citation somewhat relevant & with teaching; [Evidence Base supported with citation Scientific Information] rationale is vaguely relevant & not supported from textbook

CRITERIA 10 8 5 3 POINTS 10. Medications Lists all MAR medications Lists all MAR medications but Lists most of the Lists some MAR medications but does with relevant side effects does not include relevant side MAR not include relevant side effects and and nursing effects and nursing medications with nursing considerations specific to considerations specific to considerations specific to relevant side patient. patient and reasons why patient and why patient is effects and patient is receiving drug. receiving drug. nursing considerations specific to patient and why patient is receiving drug. CRITERIA 5 4 3 1 POINTS College of Nursing

11. General Accurate APA format, 1-2 APA format errors, Many APA No APA formatting, Organization Appropriate citations Some citations, references format errors, No citations or references included, &references, are appropriate, Inappropriate many spelling or grammar errors No spelling or grammar Minimal spelling or grammar citations or errors errors references, Many spelling or grammar errors TOTAL:

COMMENTS: ______

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STUDENT SIGNATURE: ____ DATE:

INSTRUCTOR SIGNATURE: ___ DATE: