481Concept Map 2

Pathophysiology is explained in complete detail with accurate and in-depth understanding of Admitting diagnosis. and presenting signs/symptoms supported by diagnostic tests and proposed treatment plan; APA references.

Pathophysiology is explained in some detail with some understanding of Admitting diagnosis and presenting signs/symptoms somewhat supported by diagnostic test and understanding to proposed treatment plan; with references.

Pathophysiology is explained vaguely with marginal understanding Admitting diagnosis. and presenting signs/symptoms vaguely supported by diagnostic test and vague understanding to proposed treatment plan; no references cited.

Pathophysiology details limited with poor understanding of chief complaint and presenting signs/symptoms does not support medical diagnosis, not supported by diagnostic tests and with no proposed treatment plan; no references cited.

Complete details given of other health problems (includes explanation of all relevant medical and surgical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s).

Some details given of other health problems with partial explanation of all relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).

Vague details given of other health problems with minimal explanation of relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).

No details given of other health problems, without explanation of relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).

Complete information provided about patientclient family, provides cultural point of view in illness and wellness and connects Ethnicity to health problems/ Social Determinants of Health. (APA references) Clearly and accurately identifies client’s developmental stage with explanation based on the patient’s/ client’s developmental tasks.

Some information provided about patient/client family and cultural point of view in illness and wellness, somewhat connects Ethnicity to health problems, with references/Social Determinants of Health. (APA References) Adequately identifies patient’s/client’s developmental stage with explanation based on the patient’s/client’s developmental tasks.

Vague information provided about patient/client family and cultural point of view in illness and wellness, vaguely connects Ethnicity to health problems/ limited Social Determinants of Health described, no references cited. Vaguely identifies patient’s/client’s developmental stage without explanation based on the patient’s/ client’s developmental tasks.

No information provided about patient/client family and cultural point of view in illness and wellness, establishes no connect to Ethnicity and the health problems. Limited to no Social Determinants of Health described, no references cited. Fails to identify patient’s/ client’s developmental stage and lacks any explanation based on the patient’s/client’s developmental tasks.

Complete information provided about discharge planning

Some information provided about discharge planning.

Vague about the information on discharge planning.

No information provided on discharge planning.

Documents full Head-to-Toe physical assessment – relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.

Documents Head-to-Toe physical assessment – with approx. 75% + relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.

Documents full Head-to-Toe physical assessment – with approx. 50% -75% relevant to the patient/client as performed by the student. Format may be moderately disorganized with mostly appropriate terms to describe both normal and abnormal assessment findings.

Documents full Head-to-Toe physical assessment – with approx. > 50% relevant to the patient/client missing information – as performed by the student. Format is mostly disorganized and may be lacking appropriate terms to describe both normal and abnormal assessment findings.

All nursing diagnoses are accurate and prioritized per format with clear etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.

All nursing diagnoses are adequate and prioritized per format with sufficient etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.

Any nursing diagnoses that may be vague and/or is not prioritized per format with vague etiology and unclear correlation from the data to support the diagnosis. Nursing Diagnosis are consistent and presents correlation from the assessment data.

Nursing diagnoses are low priority and/or are not prioritized per format, with vague etiology and unclear correlation from the data to supports the diagnosis. Nursing Diagnoses are not consistent and do not correlation from the assessment data.

The goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions.

The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic, and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions.

The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic, measure and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention.

The goals lack support and nonspecific from gathered data, Outcome criteria are not specific, realistic, measurable, attainable, nor timed. Does not evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention.

Clearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.

Adequately Identifies nursing/collaborative interventions with adequate teaching. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on patient’s/client’s goal and health deviation

Vaguely Identifies nursing/ collaborative interventions with unclear teaching. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the patient’s/client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis

Fails to identify nursing/ collaborative interventions and teaching. Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Interventions do not focus on patient/client goals and/or the stated health deviation based on nursing assessment

Lists all MAR medications (Routine and PRN) including name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.

Lists all MAR medications (Routine and PRN) but does not adequately medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.

Lists most MAR medications (Routine and PRN); excepts lacks medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.

Lists most MAR medications (Routine and PRN); but fails to include medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.

Clearly and accurately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

Adequately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

Vaguely identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

Fails to identify and explain abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

Accurate APA format; Appropriate citations and references; No spelling or grammar errors.

Adequate APA format; Minimal citations and references are appropriate; Few spelling or grammar errors.

Numerous APA format errors; Inaccurate citations and references; Few spelling and grammar errors.

Fails to utilize APA format; No citations or references included; Numerous spelling and grammar errors