Nursing Care Plan

Plan of Care Grading Rubric

Topic

Distribution of Points

Points Earned

Assessment Findings (data):

(Including pertinent negative findings)

• Clustered in order of priority
• Related to nursing diagnosis
• Documented source

25 points

Nursing Diagnosis:

• Prioritizing (using the NANDA format)

• Based on the data collected
• One actual and one at risk diagnoses selected

8 points

Expected Outcome:

(Attainable through nursing interventions)

• Two short-term outcomes per nursing diagnosis (16 points)
• Must be measurable with a realistic timeframe (4 points)

20 points

Interventions & rationale:

• Three nursing specific interventions for each short-term goal (not to include monitoring a patient)
• Congruent with the nursing diagnosis
• Demonstrate theoretical/scientific principles and integrate research
• Documented with supportive literature

40 points

Evaluation (rationale):

(Outcome criteria met, partially met, or not met)

2 points

Formatting:

• Grammar, spelling and terminology must be correct
• Minimal use of standard abbreviations
• References cited in APA format

5 points

Total Score

All material submitted must be typed in the space provided!

Patient’s Admitting Diagnosis:

List patient’s past medical history related to admission:

PATHOPHYSIOLOGY

Provide brief/key aspects of pathophysiology related to your patient’s admitting diagnosis in the space provided below.

Instructions for assessment:

In the space below enter the subjective and objective data gathered during your patient assessment based on systems, including laboratory and diagnostic assessments.

A

S

S

E

S

S

M

E

N

T

Subjective Data Entry

Objective Data Entry

TIME OUT!

To be sure your patient diagnostic statement written below is accurate, you need to review the assessment data and determine if it is appropriate and relevant for the diagnostic statement below.Do you have an accurate match or is additional data required or does another nursing diagnosis need to be investigated? Have you appropriately categorized the subjective and objective data? Have you prioritized and clustered your assessment data to formulate the nursing diagnosis? List at least one (1) actual and one (1) at risk nursing diagnosis for your patient.

Nursing Diagnostic Statement:

Nursing Diagnostic Label:

Related to:

As Evidenced By:

Nursing Diagnostic Statement:

Nursing Diagnostic Label:

Related to:

As Evidenced By:

TIME OUT!

The diagnostic label must be NANDA approved and describes the patient’s response to health conditions. Is there a possibility that the diagnostic label can be misunderstood as a medical diagnosis? Are the related factors displaying the reason why the patient is exhibiting the diagnostic label? Are the defining characteristics (“as evidenced by”) show the evidence of the problem? List two (2) short term goals (STG) for each nursing diagnosis.

Expected Goals/Outcomes:

Diagnosis A:

STG #1:

STG #2:

Diagnosis B:

STG #1:

STG #2:

TIME OUT!

The desired outcome must meet criteria to be accurate. The outcome must be specific, realistic, measurable, and include a time frame for completion. Does the action verb describe the patient’s behavior to be evaluated? Can the outcome be used in the evaluation step of the nursing process to measure the patient’s response to the nursing interventions listed below? List at maximum of three (3) interventions for each goal.

I

N

T

E

R

V

E

N

T

I

O

N

Interventions

A1

A2

B1

B2

Rationale for Selected Intervention Using Evidence-Based Practice (EBP) references

A1

A2

B1

B2

TIME OUT!

Do your interventions assist in achieving the desired outcome? Do your interventions address further monitoring of the patient’s response to your interventions and to the achievement of the desired outcome?Are qualifiers: when, how, amount, time, and frequency used? Is the focus of the actions of the nurse and not on the patient? Do your rationales provide sufficient reason, directions, and best evidence-based practice?

E

V

A

L

U

A

T

I

O

N

Was the desired outcome achieved? Include data and if not, or partially met, what revisions to either the desired outcome, goals, or interventions would you make?

€ Yes€ No€ Partially met

Complete this care plan using a minimum of four scholarly resources including your textbook and your ATI resources. These resources must be easily available if requested. Attach a reference list using APA format on a separate sheet of paper to this document. All resources must be current within the last 3-5 years.