NURS 210L-AB Nursing Care Plan Assignment Paper

NURS 210L-AB Nursing Care Plan Assignment Paper

Student   Date  
Instructor   Course  
Patient Initial   Unit/ Room#   DOB  
Code Status   Height/Weight  
Allergies  NURS 210L-AB Nursing Care Plan Assignment Paper

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Temp  (C/F Site) 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
NURS 210L-AB Nursing Care Plan Assignment Paper

 

 

 

 

 

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

 

NURS 210L-AB Nursing Care Plan Assignment Paper

 

 

 

 

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

 

NURS 210L-AB Nursing Care Plan Assignment Paper

 

 

 

 

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

 (“At Risk for…” nursing dx)

Inter-professional Consults,  Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

 

 

NURS 210L-AB Nursing Care Plan Assignment Paper

 

 

 

 

Contributing

Factors

Diagnostic

Label

 

   Related to

 

       As evidenced by

Signs and

Symptoms

 

NURS 210L-AB Nursing Care Plan Assignment Paper

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

 

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

 

Prioritized Independent and collaborative nursing interventions;  include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations. NURS 210L-AB Nursing Care Plan Assignment Paper

Evaluation

Goal Met, Partially Met,

 or Not Met

& Explanation

 

         
         
         
         
         
         

 NURS 210L-AB Nursing Care Plan Assignment Paper

 

MEDICATION LIST

 

Medications (with APA citations 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

               
               
               
               
               

 NURS 210L-AB Nursing Care Plan Assignment Paper

STUDENT NAME:                                                                                                          COURSE:                                                 DATE:                                                                                                                                                                                                                                      

 

PATIENT INITIALS:                                            ___________ PATIENT DISEASE/DISORDER:                                                                                                                                                                           

 

Criteria 4

Exceeds Expectations

3

Meets Expectations

2

Approaching Expectations

1-0

Does Not Meet Expectations

Score
History of Present Illness HPI explained in detail with accurate and in-depth understanding of chief complaint and supported by evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations. HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations. HPI details limited with poor understanding of chief complaint and no evidence based citations to support. NURS 210L-AB Nursing Care Plan Assignment Paper X2
Physical Assessment, & Diagnostic tests/ procedures Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations. Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely  supported by evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not  supported by evidence based citations. X2
Past Medical &

Surgical History, Pathophysiology

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 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. NURS 210L-AB Nursing Care Plan Assignment Paper 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. 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. NURS 210L-AB Nursing Care Plan Assignment Paper X2
Erikson’s

Developmental Stages

 

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations. X2
Socioeconomic/ Psychosocial Assessment Describes socioeconomic and cultural background in complete detail with references; Identifies 3 psychosocial concerns. NURS 210L-AB Nursing Care Plan Assignment Paper Describes socioeconomic and cultural background in some detail with references; Identifies 2  psychosocial concerns. Describes socioeconomic and cultural background in vague detail without references; Identifies 1 psychosocial concern. NURS 210L-AB Nursing Care Plan Assignment Paper Describes socioeconomic and cultural background

with no detail without references; Identifies no psychosocial concerns.

X1
Interprofessional

Consults & Discharge

Referrals

Lists 3 or more appropriate collaborative issues/concerns; Rationale demonstrates excellent understanding of consults and interventions. Lists 2 appropriate collaborative issues/concerns; Rationale demonstrates satisfactory

understanding of consults and interventions. NURS 210L-AB Nursing Care Plan Assignment Paper

Lists 1 appropriate collaborative issue/concern; Rationale demonstrates vague  understanding of  consults and interventions. Lists inappropriate collaborative issues/concerns; Rationale demonstrates unsatisfactory

understanding of consults and interventions.

X2
Potential Health

Deviations

Identifies TWO prioritized risk factors in proper format; Writes 3 independent nursing interventions. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies 1 prioritized risk factor in proper format; Writes 2 independent nursing interventions. Identifies 2 prioritized risk factors but not in proper format; Writes 1 independent pertinent nursing intervention. Does not identify prioritized risk factors; Writes 0-1 independent nursing intervention not pertinent to the diagnosis. NURS 210L-AB Nursing Care Plan Assignment Paper X3
Priority

Nursing Diagnosis

TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. NURS 210L-AB Nursing Care Plan Assignment Paper 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. NURS 210L-AB Nursing Care Plan Assignment Paper Written incorrectly with sufficient data to support diagnosis, not a priority. Written incorrectly, not in correct format, or without sufficient data to support diagnosis. X4
Planning/Goals &

Evaluation

Goal is measureable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions. Goal is not measureable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions. NURS 210L-AB Nursing Care Plan Assignment Paper Goal is not measureable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions. Goal is not measureable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions. X2
Implementation and

Rationale

Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using  textbook or evidence based citations. NURS 210L-AB Nursing Care Plan Assignment Paper Identifies 3 independent interventions with teaching; Scientific rationale is supported with scientific rationale using  textbook or evidence based citations. Identifies 2 independent interventions with teaching; Scientific rationale is vaguely relevant & not supported from textbook. Identifies 1 independent interventions with teaching; Scientific rationale is  not relevant & not supported from textbook. NURS 210L-AB Nursing Care Plan Assignment Paper X2
Medications Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug. NURS 210L-AB Nursing Care Plan Assignment Paper Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug. NURS 210L-AB Nursing Care Plan Assignment Paper Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug. Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient. X2
General Organization Accurate APA format; Appropriate citations & references; No spelling or grammar errors. 1-2 APA  format errors; Some  citations, references are appropriate; Minimal spelling or grammar errors.NURS 210L-AB Nursing Care Plan Assignment Paper Many APA format errors; Inappropriate citations or references; Many spelling or

grammar errors.

No APA formatting; No  citations or references included; Many spelling or grammar errors. X1
Total /100                                    %

NURS 210L-AB Nursing Care Plan Assignment Paper

COMMENTS:                                                                                                                                                                                                                                                                      

 

FACULTY SIGNATURE:                                                                                                                                      DATE:                                                                                                   

 

NURS 210L-AB Nursing Care Plan Assignment Paper