Special Instructions: Students must verify patient with clinical instructor for this assignment. Please submit this grading sheet with your completed care plan.
1. Classification/medication/dosage/route
2. Mechanism of action
3. Identifying why this pt is on the med
4. Identify possible drug interactions, side effects,
and symptoms of toxicity.
5. Relevant nursing interventions and assessments
Diagnosis & Planning Worksheet
1. Pathophysiology at the cellular level or functional (4) __________
level (cite reference).
2. List a minimum of (6) significant patient signs and (3) __________
symptoms obtained through physical assessment.
3. Collaborative Care including: lab, diagnostic imaging, (5) __________
previously ordered).
for meds and treatments when appropriate.
Student Handbook.
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Excellent
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Satisfactory
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Unsatisfactory
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Assessment
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Points Awarded:
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1
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0.5
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0
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Provides demographic information of patient while ensuring confidentiality.
(1 point)
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Demographic information page is filled out completely and patient confidentiality is completely maintained.
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Demographic information page may not be complete; or patient confidentiality is not maintained.
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Demographic information page is vague or not completed or patient confidentiality is not maintained.
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Points Awarded:
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11
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6-10
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0-5
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Utilizes Gordon’s Functional Health Patterns (GFHP) to collect complete data on patient.
(11 points possible)
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GFHP is complete in breadth and depth. All pertinent information is addressed and a clear ‘picture’ of the patient is formed through the collected data.
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GFHP may be complete, but lacking in depth of information. Pertinent information is addressed, however a clear ‘picture’ of the patient is not necessarily provided through the information presented. Subjective data may be provided in the objective data column.
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GFHP is vague or incomplete. Little pertinent information is addressed and a clear ‘picture’ of the patient is not provided.
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Points Awarded:
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10-12
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6-9
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≤ 5
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Identifies discharge planning/resource needs of patient using the discharge planning/resource guide assessment form.
(2 points possible per discharge resource)
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Discharge planning is complete. All potential resources and support are identified in detail. It is apparent that information provided is patient specific.
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Discharge planning is mostly complete. The majority of potential resources and support are identified, however information provided is not necessarily patient specific.
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Discharge planning is vague. Potential resources and support are not clearly identified and information provided is not patient specific.
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Points Awarded:
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4-5
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2-3
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0-1
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Medications:
Identifies all medications patient is taking , unless specific arrangements (otherwise) have been made with the instructor due to the complexity of the pt.
(5 points possible)
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Medication information is accurate, detailed, and patient specific. All patient medications are identified.
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Medication information is accurate, but lacking in detail and/or patient specificity. Most of the patient’s medications are identified. Interactions pertinent to this pt. with other meds. pt. was taking may not have been identified.
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Medication information is vague, incomplete, and inaccurate. Many of the patient’s medications are not identified.
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Diagnosis & Planning
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Points Awarded:
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2
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1
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0
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Worksheet Strengths:
Utilizes Gordon’s Functional Health Pattern (GFHP) assessment to determine patient’s strengths
(2 points possible)
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GFHP assessment is utilized to list all relevant patient strengths
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The majority of strengths are identified but some assessment findings may not be listed.
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There is little or no identification of strengths from the GHFP assessment.
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Points Awarded:
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4
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2-3
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0-1
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Worksheet Weaknesses:
Utilizes GFHP assessment to identify and prioritize patient weaknesses utilizing Maslow’s hierarchy of needs or another published tool for prioritizing patient needs.
(4 points possible)
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GFHP assessment is utilized to list patient’s weaknesses in priority order and Maslow’s hierarchy of needs (or other valuable resource) is utilized to prioritize weaknesses that might interfere with the patient’s health. All references are cited.
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The majority of weaknesses identified are supported by the GFHP assessment, but the prioritization may not correlate with the NANDA diagnoses, or logically follow Maslow’s hierarchy or other (evidence-based) priority order. Some assessment findings may not be listed
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The majority of relevant patient weaknesses may be missing, there may be no rationale provided for prioritization, or reference citations are completely lacking.
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Points Awarded:
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5-6
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2-4
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0-1
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Nursing Diagnosis:
Must use 2-3 part NANDA approved problem statements, (depending on whether problem is actual or risk for.) NANDA diagnoses must be associated with patient’s main pathology covered in the NCP.
(6 points possible)
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Nursing diagnoses selected are NANDA approved, follow the appropriate format, are correlated with the identified strengths/weaknesses, and are prioritized appropriately.
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The nursing diagnoses selected are NANDA approved, but may not follow the appropriate format. The diagnoses chosen may be loosely correlated with the identified strengths/weaknesses.
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The nursing diagnoses are either not NANDA approved, or do not follow the appropriate format. There may be little to no correlation between the identified strengths/weaknesses and the nursing diagnoses.
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Points Awarded:
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5-6
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2-4
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0-1
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Scientific Evidence:
Scientific, evidence-based rationale is provided for NANDA diagnoses, clearly supporting the relevance of each nursing diagnosis. Reference(s) must be cited appropriately.
(6 points possible)
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Strong evidence-based rationale is provided to support the relevance of each nursing diagnoses at the functional level. Reference(s) are cited appropriately in APA format.
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Evidence-based rationale may vaguely support the relevance of the nursing diagnoses, or evidence-based resource may not be appropriate.
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Evidence-based rationale does not support the prioritization of the nursing diagnoses, or rationale is not given.
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Points Awarded:
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4
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2-3
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0-1
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Discharge Goals/Teaching needs:
Two appropriate discharge goals and two teaching needs are noted that the student taught the patient prior to discharge.
(4 points possible)
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Discharge goals are individualized, measurable, include a timeframe, and are appropriate for the nursing diagnoses. Teaching needs involve information the patient needs to know prior to discharge and should be taught by the student.
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Discharge goals may not be individualized, measurable, include a timeframe, or are not appropriate for the nursing diagnoses. Teaching needs may not be information the patient needs to know prior to discharge or were not actually taught by student.
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Discharge goals and/or teaching needs are missing major components or not applicable for the patient’s diagnoses.
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Care Plan/ Concept Map
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Points Awarded:
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4
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2-3
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0- 2
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Criteria #1:
Describes pathophysiology of the priority medical problem at the cellular or functional level with reference cited appropriately
(4 points possible)
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Pathophysiology is accurate, detailed, complete, and patient specific. There is clear, detailed identification of the cellular or functional processes of the disease. Pathophysiology correlates with patient’s identified medical problems and reference is cited appropriately from a textbook or peer reviewed medical journal.
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Pathophysiology is accurate and complete. However it is lacking in detail and patient specificity. Cellular or functional processes of the disease are identified, but may not have sufficient detail. Pathophysiology correlates with patient’s identified medical problems.
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Pathophysiology is brief or even inaccurate. Little attention may be paid to patient specificity and to the cellular or functional processes of the disease. Pathophysiology may not correlate with identified medical problems.
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Points Awarded:
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3
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2
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0 – 1
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Criteria #2:
Identifies a minimum of six (6) significant signs and symptoms (defining characteristics) from patient assessment and identifies the GFHP# for each.
(3 points possible)
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Six significant signs/symptoms are identified that are patient specific, supported by the GFHP, and support the pathophysiology of the medical diagnosis.
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Six or less significant signs and symptoms are identified, however they may not be patient specific, or are not supported by GFHP assessment. There is weak correlation to the pathophysiology of the medical diagnosis.
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Few significant signs and symptoms are identified. They likely are not patient specific and are not supported by GFHP assessment. There may be no correlation to the pathophysiology of the medical diagnosis.
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Points Awarded:
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5
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3-4
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0-2
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Criteria #3
Collaborative Care:
Identifies and includes complete descriptions of all care that may or may not have been ordered. Must include patient specific results as well as normal findings when appropriate.
(5 points possible)
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The concept map includes a full description of all collaborative care that may or may not have been ordered to enhance the patient’s care including, but not limited to; lab, DI, PT, OT, ST, RT, clinical nutritionist, pharmacist, MD
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Some collaborative care options may have been listed but other areas, not addressed on the concept map, could have improved the patient’s plan of care. The information provided may have been incomplete.
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There was little or no notation on the concept map of actual or possibly beneficial collaborative care available for the patient.
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Points Awarded:
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5
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3-4
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0-2
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Criteria #4:
Appropriately correlates (links) the following: pathophysiology, signs and symptoms, lab values, diagnostics, nursing diagnosis and interventions, and medications.
(5 points possible)
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There is a clear correlation identified between all of the areas listed. Utilizes solid lines, dotted lines, arrows, or other technique to indicate specific correlations.
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There is a vague correlation identified between one or more of the areas listed but correlations may be too general or do not show relevance of the information.
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No correlation is identified between specific components of the areas listed or all areas are linked inappropriately.
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Points Awarded:
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3
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2
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0 - 1
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Criteria #5:
NANDA diagnoses derived from GFHP information
(3 points possible)
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Correct two or three part statements are made, using NANDA format for three nursing diagnoses from student worksheet.
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Two nursing diagnoses are listed, or NANDA format is not correctly used to state the nursing diagnoses.
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One or no nursing diagnosis is appropriately stated in NANDA format.
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Points Awarded:
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6
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4 - 5
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0 – 3
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Criteria #6:
Identifies individualized, realistic, and measurable desired outcomes, one for each nursing diagnosis, including a time frame.
(6 points possible)
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A patient specific, realistic outcome is identified that directly correlates with each nursing diagnosis. The outcome is realistic, measurable, and includes a time frame.
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A realistic outcome is identified, however it is either not patient specific or it does not directly correlate with the nursing diagnosis. The outcome is realistic, vaguely measurable and includes a time frame.
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An outcome is identified, however it is not realistic, is not patient centered, or does not correlate with the nursing diagnosis. It is vaguely (if at all) measurable and may or may not be realistic, or include a time frame.
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Points Awarded:
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5-6
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3-4
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0-2
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Criteria #7:
Selects three priority nursing interventions that are focused on the nurse’s behavior and are patient specific (consider GHFP assessment when formulating interventions) (Remember: interventions correlate and assist in achieving the desired outcome and are based on the priority nursing diagnosis).
(6 points possible)
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3 nursing interventions are identified that are directly correlated to achieving the desired outcome and addressing the nursing diagnosis. The interventions are nursing specific, clearly delineate what the nurse is to achieve (who will do what, under what circumstances, by when). Consideration is made to the patient and nurse’s strengths and limitations.
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3 nursing interventions are identified however they may or may not directly correlate to achieving the desired outcome and/or addressing the nursing diagnosis. Interventions may be vaguely nursing specific, or do not clearly delineate what the nurse is to achieve Little consideration may have been made to the patient’s and nurses’ strengths and limitations.
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Less than three nursing interventions are identified and they are not directly correlated to the desired outcome and/or the nursing diagnosis. The interventions are vaguely nursing specific, or perhaps patient specific. There is little delineation of what the nurse is to achieve or no consideration is made to the patient’s and nurse’s strengths and limitations.
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Points Awarded:
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8 - 9
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5 - 7
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0 - 4
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Criteria #8:
Identifies the evidence-based rationale for each selected nursing intervention (with references for each).
(9 points possible)
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Scientific, evidence-based rationale is provided for each nursing intervention, that clearly supports how the intervention will aide in achieving the desired outcome and addressing the nursing diagnosis. Reference(s) are cited appropriately.
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Vague evidence-based rationale may have been provided for each nursing intervention, but clear support of how the intervention will aide in achieving the desired outcome and address the nursing diagnosis may not have been provided.
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Little or no evidence-based rationale is provided. There is very little, if any, support in how the intervention will aide in achieving the desired outcome and address the nursing diagnosis.
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Points Awarded:
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3
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2
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0-1
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Criteria #9:
Evaluate the patient’s response for each intervention.
(3 points possible)
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Reflective evaluation of the patient’s observable response to each of the nursing interventions is identified.
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Vague evaluation of the patient’s response to each of the nursing interventions is identified or the response listed does not directly correlate to the achievement of the desired outcome.
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Little if any evaluation of the patient’s response to each of the nursing interventions is identified.
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Points Awarded:
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3
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1 - 2
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0
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Criteria #10:
Desired outcome met? (Include answers to the following: Was the outcome met, and was it appropriate? Were the interventions appropriate for the nursing diagnosis?)
(3 points possible)
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Reflective evaluation is provided as to whether or not the desired outcome was met and/or to what degree. Thoughtful consideration shown as to whether the outcome and interventions were appropriate for the nursing diagnosis and pt. If not met, possible changes for the future are provided.
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Evaluation of the desired outcome was met and/or to what degree is provided, however it may not have displayed reflective thought and analysis. Vague consideration may have been given related to the appropriateness of the outcomes and interventions. Changes for outcomes not met were not appropriate.
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The evaluation is not reflective and does not display thoughtful analysis. Little, if any, consideration is shown related to the appropriateness of the outcomes and interventions. No possible changes were given for outcomes not met.
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Points Awarded:
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1
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0.5
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0
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Web assignment
(1 points possible)
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Hard copy of online patient teaching resource is attached to NCP. Information uses terminology that is appropriate for patient’s learning level.
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Online teaching resource is attached but the information is either inadequate or it is worded in language that is not appropriate for the level of learning of the patient.
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Online teaching resource is missing.
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Points Awarded:
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9-11
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5-8
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0 – 4
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APA: Title page, running head, and references according to APA 5th ed. format and criteria as outlined in the student handbook.
(11 points possible)
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APA format is nearly perfect. No spelling or grammatical errors, etc. Consideration is given to number of references. Pt confidentiality is maintained. All references listed on reference page were cited in the body of the paper.
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Few APA format errors. Occasional spelling and/or grammatical errors, which did not obscure the meaning. Consideration is given to number of references. Pt confidentiality is maintained.
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Major APA formatting errors. Frequent spelling and/or grammatical errors that obscure the meaning of the paper. No consideration is given to number or references, and/or pt. confidentiality is broken. Reference page may have been missing.
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