care plan

care plan

Page 1 of 10 Nursing Care Plan NURSING (AS) Program Student Name: ____________________________________ Date: ____ / ____/ ______ Initial: Sex: M / F Date of Admission: / / Admitting Diagnoses: 1) 2) 3) 4) 5) Patient Past Medical History: Instructor: __________________________ Clinical Site: _______________________________ Patient Information Age: Ethnic Group: Allergy: Weight: Past Surgical History: Social History: History of Present Illness: (If additional Space is needed please continue on the back of this page) NURSING CARE PLAN White / AA / Hispanic / Asian Diet: Page 2 of 10 Subjective Findings (If additional space is needed please continue on the back of this page) Vital Sign: BP: HR: RR: Objective Finding Temp: Physical Assessment Findings: Laboratory Studies: CBC NURSING CARE PLAN Metabolic Panel Coagulation Other: (U/A, ABG’s, Protombin, etc.) Page 3 of 10 Imaging Result: (X-Ray, CT Scan, MRI, MRCP, Ultrasound…….) Endoscopic Result: (colonoscopy, EGD…..) What is the relation between these diagnostic tests with the patients disease and or present illness? NURSING CARE PLAN Page 4 of 10 Analysis: What are the potential complications / problems for this patient? NURSING CARE PLAN Page 5 of 10 Medication List Medication/Order NURSING CARE PLAN Usage Usual Dose Side effects Nursing Intervention Page 6 of 10 Nursing Care Plan Once evaluated patient’s past and present history: select at least three nursing diagnoses from highest to lowest priority. Give nursing interventions (dependent/independent/collaborative) for each nursing diagnoses with rational for each intervention. Determine a short and long term goal for each nursing diagnoses. Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 7 of 10 Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 8 of 10 Nursing Diagnoses (…..related to…..secondary to ….evidenced by…..) NURSING CARE PLAN Desired Outcome Nursing Interventions / Rationales Page 9 of 10 Patient’s Care Plan Evaluation of Outcomes: NURSING CARE PLAN Page 10 of 10 Student Evaluation (To be completed by faculty only) Comments: Student Needs to Improve on: FINAL GRADE: _____________________ Instructor’s Signature: _____________________________ Date of evaluation: _________________ Student’s Signature: _______________________________ NURSING CARE PLAN

  Excellent Good Fair Poor
Main Posting 45 (45%) – 50 (50%)

Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.

 

Supported by at least three current, credible sources.

 

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

40 (40%) – 44 (44%)

Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.

 

At least 75% of post has exceptional depth and breadth.

 

Supported by at least three credible sources.

 

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

35 (35%) – 39 (39%)

Responds to some of the discussion question(s).

 

One or two criteria are not addressed or are superficially addressed.

 

Is somewhat lacking reflection and critical analysis and synthesis.

 

Somewhat represents knowledge gained from the course readings for the module.

 

Post is cited with two credible sources.

 

Written somewhat concisely; may contain more than two spelling or grammatical errors.

 

Contains some APA formatting errors.

0 (0%) – 34 (34%)

Does not respond to the discussion question(s) adequately.

 

Lacks depth or superficially addresses criteria.

 

Lacks reflection and critical analysis and synthesis.

 

Does not represent knowledge gained from the course readings for the module.

 

Contains only one or no credible sources.

 

Not written clearly or concisely.

 

Contains more than two spelling or grammatical errors.

 

Does not adhere to current APA manual writing rules and style.

Main Post: Timeliness 10 (10%) – 10 (10%)

Posts main post by day 3.

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

Does not post by day 3.

First Response 17 (17%) – 18 (18%)

Response exhibits synthesis, critical thinking, and application to practice settings.

 

Responds fully to questions posed by faculty.

 

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

 

Demonstrates synthesis and understanding of learning objectives.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are fully answered, if posed.

 

Response is effectively written in standard, edited English.

15 (15%) – 16 (16%)

Response exhibits critical thinking and application to practice settings.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are answered, if posed.

 

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

 

Response is effectively written in standard, edited English.

13 (13%) – 14 (14%)

Response is on topic and may have some depth.

 

Responses posted in the discussion may lack effective professional communication.

 

Responses to faculty questions are somewhat answered, if posed.

 

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

0 (0%) – 12 (12%)

Response may not be on topic and lacks depth.

 

Responses posted in the discussion lack effective professional communication.

 

Responses to faculty questions are missing.

 

No credible sources are cited.

Second Response 16 (16%) – 17 (17%)

Response exhibits synthesis, critical thinking, and application to practice settings.

 

Responds fully to questions posed by faculty.

 

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

 

Demonstrates synthesis and understanding of learning objectives.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are fully answered, if posed.

 

Response is effectively written in standard, edited English.

14 (14%) – 15 (15%)

Response exhibits critical thinking and application to practice settings.

 

Communication is professional and respectful to colleagues.

 

Responses to faculty questions are answered, if posed.

 

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

 

Response is effectively written in standard, edited English.

12 (12%) – 13 (13%)

Response is on topic and may have some depth.

 

Responses posted in the discussion may lack effective professional communication.

 

Responses to faculty questions are somewhat answered, if posed.

 

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

0 (0%) – 11 (11%)

Response may not be on topic and lacks depth.

 

Responses posted in the discussion lack effective professional communication.

 

Responses to faculty questions are missing.

 

No credible sources are cited.

Participation 5 (5%) – 5 (5%)

Meets requirements for participation by posting on three different days.

0 (0%) – 0 (0%) 0 (0%) – 0 (0%) 0 (0%) – 0 (0%)

Does not meet requirements for participation by posting on 3 different days.

Total Points: 100