SECTION
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EXCELLENT
(Exceeds standard –meets satisfactory criteria and adds the following)
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SATISFACTORY
(Meets standard- passing)
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UNSATISFACTORY
(Below standard-not passing)
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NURSING ASSESSMENT |
Data Collection
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•Individualizes appropriately gathered assessment data.
•Discusses cultural, spiritual, psychological, values appropriately.
•Discusses demographic information thoroughly.
•Describes pathophysiology in depth
•Explains surgery correctly and in depth.
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•Lists demographic data with only minor points missing.
•Lists standards, protocols, critical pathways, flow sheets.
•Lists sources of data.
•Lists appropriate text resources for medical diagnoses and surgery.
•Discusses surgery correctly
•Assesses all systems/human needs each day, with minor data missing.
•Discusses functional status
•Lists an appropriate theorist on each NPP.
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•Omits major assessment data.
•Omits demographic data
•Omits standards, protocols, critical pathways.
•Omits sources of data.
•Uses inappropriate resources for medical diagnoses.
•Does not discuss surgery
•Omits key points on data
•Lists only data for day 1 or day 2.
•Misses clear focus of assessment.
•Omits functional assessment.
•Omits theorist.
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Medications/
Intravenous (IV) solutions
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•Describes clear, accurate classifications and sub-classifications of medications.
•Lists specific and accurate
purpose for this patient.
•Relates medications to patient’s medical diagnosis and laboratory tests.
•Describes accurate and complete nursing orders and implications.
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•Lists generic/ trade names and classifications with minor points missing.
•Lists dose, route, and frequency including times.
•Lists general purpose of medication for this patient.
•Omits minor data.
•Describes safe nursing orders and implications.
•Lists appropriate IV solutions and blood products.
•Lists 2 appropriate common side effects.
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•Omits critical medication information when suggested.
•Omits key information.
•Omits generic/ trade names and classifications.
•Omits dose, route, and frequency including times.
•Omits purpose.
•Does not describe safe nursing orders and implications.
•Does not ask for assistance to describe safe nursing orders and implications.
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Laboratory data/ Diagnostic testing
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•Lists total HGB, HCT., UA, ABG’s and electrolytes if available.
•Discusses abnormal tests & identifies trends.
•Lists appropriate drug levels or states if not available.
•Relates tests to medical diagnoses and medications.
•Discusses diagnostic tests appropriately.
•Describes specific independent nursing actions related to critical tests.
•Describes specific collaborative nursing actions related to critical tests with assistance.
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•Discusses abnormal tests with minor information or data missing.
•Relates tests to medications and medical condition with assistance.
•Lists possible etiology with assistance if necessary
•Lists dates of tests.
•Describes general independent nursing actions related to tests.
•Describes general collaborate nursing actions related to critical tests with assistance.
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•Omits abnormal and critical lab and diagnostic test information.
•Omits key points.
•Omits dates of tests.
•Omits possible etiology.
•Omits normal range.
•Omits independent nursing actions related to selected tests.
•Omits general collaborate nursing actions related to critical tests.
•Does not ask for assistance to understand critical data.
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ANALYSIS: Nursing diagnoses and Collaborative Problems. (Nursing diagnosis processed )
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Actual and High Risk nursing diagnoses
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•Writes nursing diagnoses completely and accurately in PES format that are specific to the patient’s condition.
•Identifies defining characteristics accurately for this patient.
•Prioritizes nursing diagnoses
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•Includes NANDA terminology that is appropriate for patient.
•Writes nursing diagnoses completely and accurately in PES format.
•Includes etiology factors (“related to” and then “secondary to” when known).
•Includes major and minor defining characteristics supported by assessment data.
•Processes nursing diagnosis that is relevant to N142.
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•Lists less than three complete nursing diagnosis.
•Lists incomplete nursing diagnoses.
•Lists inaccurate or inappropriate nursing diagnoses.
•Omits critical parts of major and minor defining characteristics.
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Collaborative problems/ Potential Complications
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•Relates to current medical diagnoses & current condition.
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•Lists probable potential complications that are relevant to patient’s chief medical diagnoses.
•Uses correct terminology and format.
•Relates medical diagnosis to the potential complication.
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•Lists none.
•Uses nursing diagnoses as potential complications.
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Health teaching
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•Applies analysis of problems and strengths to discharge plans.
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•Includes problems and strengths in each data section.
•Discusses analysis of problems and strengths of patient.
•Analyzes health teaching needs.
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•Omits problems and strengths data in one or more sections.
•Not done.
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PLANNING |
Discharge problems, needs & plans
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•Clear and complete.
•Uses sources in gathering data.
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•Misses major points.
•Relates to patient.
•Cites source of information.
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•Misses major points
•Lists none
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Laboratory tests-implications for independent/ collaborative nursing care
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•Implications for collaborative and independent nursing care complete.
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•Omits minor points for collaborative nursing & independent nursing care.
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•Not done or inaccurate.
•Omits key points.
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Desired outcomes
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•Individualizes to patient.
•Uses collected data in outcome.
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•Lists 2-3 outcomes.
•Lists clearly stated patient focuses outcomes.
•Lists accurate short and long term outcomes.
•Uses realistic time limits.
•Writes outcomes related to nursing diagnosis lists.
•Misses minor points
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•Uses unrealistic nursing outcome.
•Does not relate outcomes to nursing diagnoses.
•Lists only one or part of one outcome.
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Planned interventions
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•Uses several priority interventions.
•Uses SOC, protocols, resources, care pathways uses.
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•Uses several interventions for 1 outcome.
•Uses most data collected.
•Some resources uses.
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•Lists inappropriate interventions for student or patient.
•Uses outcomes with a narrow focus.
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Rationale statements
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•Lists complete statements.
•Lists statements specific to patient.
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•References appropriate texts.
•Clear & correct.
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•Lists no or partial references.
•Lists inappropriate rationale for student.
•Lists inappropriate rationale for intervention.
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IMPLEMENTATION
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Interventions
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•Prioritizes in a systematic way.
•Uses consistent interventions
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•Checks off nursing actions carries out.
•Implemented appropriate nursing actions.
•Discusses appropriate rationale for not implementing intervention.
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•Carries out inappropriate or unsafe nursing actions.
•Does not validate nursing actions with staff or instructor.
•Does not check off nursing actions.
•Lists little or no rationale on why interventions not carried out.
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EVALUATION
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Evaluation of nursing process
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•Discusses all 3 areas clearly
1) progress toward outcomes
2) overall nursing process
3) suggestions for revisions.
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•Discusses general progress toward outcome statements with minor omissions.
•Omits minor points for revision and overall nursing process.
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•Evaluation not done or vague.
•Omits key points.
•Discusses only 1 aspect of evaluation.
•Relates evaluation to intervention not the outcomes.
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Evaluation of medications
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•Individualizes nursing actions.
•Relates medications to lab testing & medical diagnoses.
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•Minor omissions on nursing actions and effectiveness of routine and PRN meds (whether given or not given).
•Asks for assistance to understand.
•Lists effects of medications given.
•Lists why medication not given.
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•Not done or inaccurate.
•Omits discussion of administration of PRN meds.
•Omits key points on nursing actions and effectiveness of meds.
•Does not ask for assistance to better understand meds/actions.
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Text references: Yes____ No___
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Spelling Yes__ No___
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SECTION
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EXCELLENT
(Exceeds standard- meets satisfactory criteria and adds the following)
|
SATISFACTORY
(Meets standard- passing)
|
UNSATISFACTORY
(Below standard- not passing)
|
NURSING ASSESSMENT
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1. Data Collection
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-Describes pathophysiology in depth and in own words
-Relates surgery and/or procedures to nursing care
-Uses pathophysiology text
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-Completes patient identification data accurately
-Lists correct medical diagnoses
-Lists pertinent health history
-Explains surgery and/or procedures
-Describes pathophysiology using appropriate resource, i.e., med-surg text and relates to patient's risk factors/symptoms
-Identifies Standards of Care/ Protocols related to patient's care
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-Omits patient data or it is inaccurate
-Omits Standards of Care
-Defines pathophysiology but does not clearly describe it (taken from text or medical dictionary) and does not relate to patient or omits pathophysiology.
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2. Medications/IVs
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-Describes all medications completely and accurately
-Relates medications to patient's diagnoses
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-Lists generic/trade names and includes classification
-Lists dose, route, frequency
-Describes specific purpose of medications for patient
-Describes nursing implications
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-Omits medication information or it is inaccurate
-Omits nursing implications or they are inappropriate
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3. Laboratory/Diagnostic Tests
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-Identifies trends over time
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-Lists test results that are pertinent to medical diagnosies and patient's progress
-Analyzes significance of tests- relates to assessment & nursing diagnoses accurately
-Describes nursing implications- collaborative and independent nursing actions appropriate to findings of test results
-Includes therapeutic drug levels when available
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-Omits test information or it is inccurate
-Omits nursing implications or they are inappropriate
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4. Systems/Human Needs
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Includes critical data relevant to medical diagnosis
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-Documents assessment of each body system completely and accurately
-Includes critical assessment data relevant to patient's diagnoses
-Notes second day changes
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-Omits assessment data or it is inaccurate
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ANALYSIS (Nursing Diagnoses & Collaborative Problems)
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1. Actual/High Risk Nursing Diagnoses (4-6)
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-Writes nursing Diagnoses completely and accurately in PES format and appropriate to patient
-Prioritizes problems based on patient's needs
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-Writes nursing diagnoses completely and accurately in PES format using correct NANDA terminology that are appropriate to patient
-Includes etiology (R/T) factors
-Includes defining characteristics supported by assessment data
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-Writes inappropriate nursing diagnoses
-Supports diagnoses with defining characteristics that are not in assessment data
-Uses incorrect defining characteristics.
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2. Collaborative Problems/ Potential Complications (1-2)
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-Identifies how to recognize the potential complication and the appropriate nursing actions to take
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-Lists potential complications that are accurate and relevant to patient's diagnosis
-Uses correct terminology
-Identifies risk factors
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-Lists problems that are inaccurate and/or irrelevant or omits problems.
-Omits risk factors
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PLAN: Select one nursing diagnosis for Individualized Plan of Care
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1. Discharge Problems, Needs & Plans
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Discharge plan complete and accurate
Includes patient education materials, interdisciplinary team, or community resources
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-States discharge needs and plan related to diet, activity, medications, community resources, and therapies as appropriate
-Includes patient teaching needs and follow-up care
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-Omits key points or information is inaccurate
-Omits discharge plan
-Writes plan that is unrealistic for patient and/or nurse
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2. Desired Outcomes
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Outcomes clearly stated and accurate
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-States outcomes clearly and accurately
-Writes outcomes that are patient-focused and related to nursing diagnosis
-Writes outcomes that are measurable, realistic, and time-limited
-Writes outcomes that are appropriate for nurse
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-Writes outcomes that are not clear, accurate, measurable, realistic, or time-limited
-Omits outcomes
-Does not relate outcomes to nursing diagnosis
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3. Nursing Interventions
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-Incorporates prescribed therapies, medications, and diagnostic tests from kardex, Standards of Care or Protocols into Plan of Care
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-Lists nursing interventions that are appropriate for outcome, nurse focused, and individualized to patient
-Lists interventions that are realistic for student to carry out
-Includes rationales that are clear and correct
-Bases interventions on appropriate references, standards., or protocols
-Identifies nursing implications for prescribed treatments, medications, and/or diagnostic tests
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-Omits critical interventions or they are not appropriate or specific to patient
-Omits references
-Lists interventions that are not realistic
-Omits nursing implications for prescribed therapies
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IMPLEMENTATION
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1. Nursing Interventions
Carried Out
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-Incorporates Standards of Care/Protocols when actually caring for patient
-Describes how interventions provide for continuity of care
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-Checks off nursing interventions that have been carried out
-Identifies interventions that are appropriate for patient and student
-Identifies interventions carried out related to prescribed therapies: medications, oxygen, diagnostic tests, tubes, etc.
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-Omits checking off interventions or they are not appropriate
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EVALUATION
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1. Evaluates Patient's Response to Interventions
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-Relates patient's response toward outcomes
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-Describes patient's response to interventions as to whether outcomes have been achieved or only partially met (progress made toward the outcomes) to show problem is resolved or resolving
-Describes data completely and accurately
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-Omits critical information in evaluation or omits evaluation or it is vague and inaccurate
-Evaluates the interventions instead of progress toward the outcomes- is not patient-focused
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2. Gives Suggestions for Revising Plan
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-Incorporates revisions into actual plan of care for patient
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-Evaluates each step of the nursing process and discusses suggestions for revising plan of care
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-Omits critical points or plan for revision is not accurate
-Omits suggestions for revising plan of care or they are inappropriate
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3. Evaluation of Medications
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-Relates medications to desired outcomes/potential complications
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-Describes effectiveness of medications
-Describes actual side effects of medications
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-Omits critical points on evaluation of medications
-Omits evaluation of medications
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Mechanics of NPP:
---Spelling
---Legibility
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SECTION
|
EXCELLENT
(Exceeds standard- meets satisfactory criteria and adds the following)
|
SATISFACTORY
(Meets standard- passing)
|
UNSATISFACTORY
(Below standard- not passing)
|
NURSING ASSESSMENT
|
1. Data Collection
|
-Describes pathophysiology in depth and in own words
-Relates surgery and/or procedures to nursing care
-Uses pathophysiology text
|
-Completes patient identification data accurately
-Lists correct medical diagnoses
-Lists pertinent health history
-Explains surgery and/or procedures
-Describes pathophysiology including risk factors and signs/ symptoms of the disorder
-Identifies to risk factors and signs/symptoms as they relate to the patient
-Uses appropriate resource
-Identifies Standards of Care/ Protocols related to patient's care
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-Omits critical patient data or it is inaccurate
-Omits Standards of Care
-Omits pathophysiology
or is unclear in the description of pathophysiology
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2. Medications/IVs
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-Describes all medications completely and accurately
-Relates medications to patient's diagnoses
|
-Lists generic names of all medications ordered for the patient
-Lists each medication’s dose, route, frequency
-Describes classification and specific purpose each medication that the patient has ordered
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-Omits critical medication information or it is inaccurate
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3. Laboratory/Diagnostic Tests
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-Identifies trends over time
-Identifies nursing actions which the student implemented to correct a problem identified by test results
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-Lists test results that are pertinent to medical diagnoses and patient's progress
-Analyzes significance of tests- relates to assessment & nursing diagnoses accurately
-Describes nursing implications- specific collaborative and independent nursing actions appropriate to findings of test results
-Includes therapeutic drug levels when available
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-Omits critical test information or it is inaccurate or inappropriate
Omits collaborative and independent nursing actions
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4. Systems/Human Needs
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-Includes critical data relevant to medical diagnosis
-Provides relevant assessment data in a clear, succinct and informative manner
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-Documents assessment of each body system completely and accurately
-Includes critical assessment data relevant to patient's medical and nursing diagnoses and patient’s condition.
-Notes second day changes
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-Omits critical assessment data relevant to diagnoses
Vital sign s are incomplete
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Analysis:
Nursing Diagnoses & Collaborative Problems
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1. Actual/High Risk Nursing Diagnoses (2-3)
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-Prioritizes problems based on patient's needs
|
-Writes nursing diagnoses completely and accurately in PES format using correct NANDA terminology that are appropriate and individualized to patient
-Includes relevant etiology (R/T) factors
-Includes relevant defining characteristics supported by data found in the assessment
-Identifies psychosocial nursing diagnosis appropriate for patient
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-Omits critical nursing diagnoses information
-Writes nursing diagnoses that are inaccurate or inappropriate for patient
Assessment data not included for nursing diagnoses
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2. Collaborative Problems/ Potential Complications (1-2)
|
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-Lists potential complications that are accurate and relevant to patient's diagnosis
-Uses correct terminology and collaborative problems format
-Includes relevant risk factors
|
-Omits collaborative problems or includes ones that are inappropriate for patient
Omits risk factors.
Lacks As Evidenced By information
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PLAN: Select one nursing diagnosis for Individualized Plan of Care
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1. Discharge Plans
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-Providing patient with educational, community resource and/ or discharge teaching information.
-Demonstrates involvement in discharge plan
Includes all disciplines in the discharge plan
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-Identifies and Documents agency discharge plan
-Includes desired outcome of discharge plan
-Includes all disciplines and their role in plan
-Includes role of nursing student in plan
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-Omits discharge plan
-Does not identify any key points of discharge plan
Omits some key points or information is inaccurate
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2. Desired Outcomes
|
Outcomes clearly stated and accurate
|
-States outcomes clearly and accurately
-Writes outcomes that are patient-focused and related to nursing diagnosis
-Includes both short and long term outcomes
-Writes outcomes that are measurable, realistic, time-limited, and individualized to the patient
-Writes outcomes that are appropriate for nurse
Writes collaborative problem outcomes which shows the nurses accountability
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-Writes outcomes that are not clear, accurate, measurable, realistic, individualized to the patient or time-limited
-Does not relate outcomes to nursing diagnosis or omits outcomes
|
3. Nursing Interventions & Rationales
|
-Incorporates prescribed therapies, medications, and diagnostic tests from kardex, Standards of Care or Protocols into Plan of Care
|
-Lists nursing interventions that are appropriate for achieving the outcome, that are nurse focused, and individualized to patient
-Lists interventions that are realistic for student to carry out
-Includes rationales that are clear and correct
-Bases interventions on appropriate references, standards., or protocols
-Identifies nursing implications for prescribed treatments, medications, and/or diagnostic tests
|
Omits critical interventions or they are not appropriate, realistic or specific to patient
-Omits references
-Omits nursing implications for prescribed therapies
-Does not specify which interventions go with which outcomes
|
IMPLEMENTATION
|
1. Nursing Interventions
Carried Out
|
-Incorporates Standards of Care/Protocols when actually caring for patient
-Describes how interventions provide for continuity of care
-Incorporates interventions into agency’s care plan for patient
|
-Checks off nursing interventions that have been carried out
-Identifies interventions that are appropriate for patient and student
-Identifies collaborative and independent interventions
Lists actions that are part of the agency plan
|
Omits checking off interventions or they are not appropriate
|
EVALUATION
|
1. Evaluates Patient's Response to Interventions
|
-Relates patient's response toward outcomes
-Discusses the interventions which were not implemented and whether implementing them will assist with achieving the outcomes
|
-Identifies each outcome as either “Met” “Partially Met” or “Not Met”
-Describes patient's response to interventions in relationship to whether outcomes have been achieved or only partially met (progress made toward the outcomes) to show problem is resolved or resolving
-Describes data completely and accurately
|
-Omits evaluation or it is vague and inaccurate
-Evaluates the interventions instead of progress toward the outcomes- is not patient-focused
|
2. Gives Suggestions for Revising Plan
|
-Incorporates revisions into actual plan of care for patient
|
-Evaluates each “Partial Met” or “Not Met” outcome and suggests how revising plan of care will achieve or improve those outcomes
|
--Omits critical points or plan for revision is not accurate or they are inappropriate
|
3. Evaluation of Medications
|
-Relates medications to desired outcomes/potential complications
-Evaluates medications effectiveness and side effects of medications given on the previous shift.
|
-Describes effectiveness of all administered medications
-Describes actual side effects of all administered medications
|
-Omits or is vague about critical points in evaluating of medications or actual side effects
|
|
Mechanics of NPP:
---Spelling
---Legibility
|
Discusses nursing actions taken to address significant side effects or ineffective medications.
-No misspellings
|
-
Some misspellings but intent is easily understood
-Legible
|
-Can not understand intent
Illegible
-Repetitively uses inappropriate words, non-standardized abbreviations
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