Nursing care plan for a pediatric patient. Disease and age of your choice.

Nursing care plan for a pediatric patient. Disease and age of your choice.


Course: NURS 317L
NURSING CARE PLAN RUBRIC
NURS 101L, NURS 210L-AB, NURS 317L
STUDENT NAME:
PATIENT INITIALS:
Criteria
COURSE:
___________ PATIENT DISEASE/DISORDER:
4
Exceeds Expectations
History of Present
Illness
HPI explained in detail with
accurate and in-depth
understanding of chief
complaint and supported by
evidence based citations.
Physical Assessment,
& Diagnostic tests/
procedures
Identifies 5-6 key
assessments parameters
relevant to medical
diagnoses with relevant
diagnostic procedures
supported by evidence
based citations.
Past medical/surgical
history detailed with full
explanation of
Pathophysiology for each
diagnosis & accurate details
with specific detail related
to the client’s history and
symptoms and supported by
evidence based citations.
Past Medical &
Surgical History,
Pathophysiology
Erikson’s
Developmental
Stages
Page 1 of 3
DATE:
Identifies and defines
correct stage with examples
of meeting/not meeting
tasks supported by evidence
based citations.
3
Meets Expectations
HPI explained in some detail
with moderate
understanding of chief
complaint or no support
from evidence based
citations.
Identifies 3-4 key
assessments parameters
relevant to medical
diagnosis with relevant
diagnostic procedures
supported by evidence
based citations.
Past medical/surgical
history given with partial
explanation of identified
preexisting medical
diagnoses & explanation
accurate with some detail
related to the client’s
history and symptoms.
supported by evidence
based citations.
Identifies and defines
correct stage with examples
of meeting/not meeting
tasks supported by evidence
based citations.
2
Approaching Expectations
HPI explained in limited
detail with marginal
understanding of chief
complaint and no support
from evidence based
citations.
Identifies 1-2 key
assessments parameters
relevant to medical
diagnosis, relevant
diagnostic procedures and
vaguely supported by
evidence based citations.
Past medical/surgical
history given with minimal
explanation of identified
preexisting medical
diagnoses & few details
related to the client’s
history and symptoms or
not supported by evidence
based citations.
Identifies correct stage
without adequate definition
or example of meeting/not
meeting tasks without
evidence based citations.
1-0
Does Not Meet
Expectations
HPI details limited with poor
understanding of chief
complaint and no evidence
based citations to support.
Score
Identifies assessments
parameters not relevant to
medical diagnoses, relevant
diagnostic procedures or
not supported by evidence
based citations.
X2
No past medical/surgical
history given without
explanation; no pre-existing
medical diagnosis identified
or explanations inaccurate
and not related to the
client’s history and
symptoms without
evidence.
X2
Identifies incorrect stage
without definition or
inappropriate examples
given, not supported by
evidence based citations.
X2
X2
Course: NURS 317L
NURSING CARE PLAN RUBRIC
NURS 101L, NURS 210L-AB, NURS 317L
Criteria
Socioeconomic/
Psychosocial
Assessment
Interprofessional
Consults &
Discharge
Referrals
Potential Health
Deviations
Priority
Nursing Diagnosis
4
Exceeds Expectations
Describes socioeconomic
and cultural background in
complete detail with
references; Identifies 3
psychosocial concerns.
Lists 3 or more appropriate
collaborative
issues/concerns; Rationale
demonstrates excellent
understanding of consults
and interventions.
Identifies TWO prioritized
risk factors in proper
format; Writes 3
independent nursing
interventions.
TWO (2) prioritized
diagnoses written correctly
with proper format with
proper etiology with
sufficient data to support
the diagnosis.
Planning/Goals &
Evaluation
Goal is measureable,
realistic, related to the
problem; Data supports if
goal is met, not met with
appropriate revisions.
Implementation and
Rationale
Identifies 4 independent
interventions with teaching;
Each is supported with
scientific rationale using
Page 2 of 3
3
Meets Expectations
Describes socioeconomic
and cultural background in
some detail with references;
Identifies 2 psychosocial
concerns.
Lists 2 appropriate
collaborative
issues/concerns; Rationale
demonstrates satisfactory
understanding of consults
and interventions.
Identifies 1 prioritized risk
factor in proper format;
Writes 2 independent
nursing interventions.
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.
Goal is not measureable,
realistic, related to the
problem; Data somewhat
supports if goal is met, not
met with appropriate
revisions.
Identifies 3 independent
interventions with teaching;
Scientific rationale is
supported with scientific
2
Approaching Expectations
Describes socioeconomic
and cultural background in
vague detail without
references; Identifies 1
psychosocial concern.
Lists 1 appropriate
collaborative issue/concern;
Rationale demonstrates
vague understanding of
consults and interventions.
Identifies 2 prioritized risk
factors but not in proper
format; Writes 1
independent pertinent
nursing intervention.
Written incorrectly with
sufficient data to support
diagnosis, not a priority.
Goal is not measureable,
not realistic, related to the
problem; Data vaguely
supports if goal is met, not
met with inappropriate
revisions.
Identifies 2 independent
interventions with teaching;
Scientific rationale is
1-0
Does Not Meet
Expectations
Describes socioeconomic
and cultural background
with no detail without
references; Identifies no
psychosocial concerns.
Lists inappropriate
collaborative
issues/concerns; Rationale
demonstrates unsatisfactory
understanding of consults
and interventions.
Does not identify prioritized
risk factors; Writes 0-1
independent nursing
intervention not pertinent
to the diagnosis.
Written incorrectly, not in
correct format, or without
sufficient data to support
diagnosis.
Score
Goal is not measureable,
not realistic, not related to
the problem; Data does not
support if goal is met, not
met with inappropriate
revisions.
Identifies 1 independent
interventions with teaching;
Scientific rationale is not
X2
X1
X2
X3
X4
X2
Course: NURS 317L
NURSING CARE PLAN RUBRIC
NURS 101L, NURS 210L-AB, NURS 317L
Criteria
Medications
General
Organization
4
Exceeds Expectations
textbook or evidence based
citations.
Lists all MAR medications
with relevant side effects
and nursing considerations
specific to patient and
reasons why patient is
receiving drug.
Accurate APA format;
Appropriate citations &
references; No spelling or
grammar errors.
3
Meets Expectations
rationale using textbook or
evidence based citations.
Lists all MAR medications
but does not include
relevant side effects and
nursing considerations
specific to patient and why
patient is receiving drug.
1-2 APA format errors;
Some citations, references
are appropriate; Minimal
spelling or grammar errors.
2
Approaching Expectations
vaguely relevant & not
supported from textbook.
Lists most of the MAR
medications with relevant
side effects and nursing
considerations specific to
patient and why patient is
receiving drug.
Many APA format errors;
Inappropriate citations or
references; Many spelling or
grammar errors.
1-0
Does Not Meet
Expectations
relevant & not supported
from textbook.
Lists some MAR medications
but does not include
relevant side effects and
nursing considerations
specific to patient.
Score
No APA formatting; No
citations or references
included; Many spelling or
grammar errors.
Total
X1
X2
/100
%
COMMENTS:
FACULTY SIGNATURE:
Page 3 of 3
DATE:
Course: NURS 317L
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
Student
Instructor
Patient Initial
Code Status
Allergies
Temp (C/F Site)
Date
Course
DOB
Height/Weight
Unit/ Room#
Pulse (Site)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
Pain Scale 1-10
History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based
Citations
Physical Assessment Findings including presenting signs and
symptoms supported with Evidence Based Citations
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values
(with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with
Evidence Based Citations
Page 1 of 3
Course: NURS 317L
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
Potential Health Deviations, Predisposing & Related Factors; (At least
two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx)
Diagnostic
Label
Priority Nursing
Diagnosis
(at least 2)
Written in three part
statement
Page 2 of 3
Related to
Planning
(outcome/goal)
Measureable goal during
your shift
(at least 1 per Nursing
diagnosis)
Inter-professional Consults, Discharge Referrals, & Current Orders
(include diet, test, and treatments) with Rationale
supported with Evidence Based Citations
Contributing
Factors
Prioritized Independent and
collaborative nursing
interventions; include
further assessment,
intervention and teaching
(at least 4 per goal)
As evidenced by
Rationale Each must be
supported with Evidence Based
Citations
Signs and
Symptoms
Evaluation
Goal Met, Partially
Met,
or Not Met
& Explanation
Course: NURS 317L
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 317L
MEDICATION LIST
Medications
(with APA
citations
Page 3 of 3
Class/Purpose
Route
Frequency
Dose (& range)
If out of range,
why?
Mechanism of
action
Onset of action
Common side
effects
Nursing
considerations
specific to this
patient

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