HOSPITAL - NURSING CARE PLAN GRADING CRITERIA RNSG 2262

Transcription

1 Student Date HOSPITAL - NURSING CARE PLAN GRADING CRITERIA RNSG 2262 CRITERIA I. ASSESSMENT (20%) Assessments are complete, specific and non-judgmental Psycho/Socio/Cultural - 3 Communicator - 2 Developmental - 4 Biological - 11 Nerv-2; CV-1; Resp-2; GI-2; MS-1; Integ-2; GU/Endo/Rep-1 Available Points 20 pts Earned II. ANALYSIS (15%) Diagnosis and Prioritizing 1. Formulates 3 nursing diagnoses which are actual or potential and based on client data. Each statement uses the PES format. Each diagnosis worth 4 pts. 2. Prioritizes nursing diagnoses and identifies rationale for priority. 12 pts 3 pts III. PLANNING (25%) Goals/Outcome Criteria All diagnoses in proper order = 3 pts. One out of order = - 1 pt. Two out of order = - 2 pts. Leaving out priority problem or adding non-priority = - 2 pts. 1. Goals are consistent with the problem, one for each diagnosis. Each goal worth 1 pt. 2. Date and time at bottom of expected outcome criteria. 3 pts 1 pt IV. IMPLEMENTING NURSING ORDERS (25%) 3. Outcome criteria are related to the goal, written in realistic, behavioral terms and includes specific, individualized and measurable outcomes. = 7 pts If all are written as nursing orders = -4 pts It leaves out important outcome criteria = -2 pts For each outcome that is applicable but not measurable = -1 pt 21 pts 1. Signature, date and time at bottom of column = 1 pt 1 pt Nursing Orders and Rationale 2. Develop a minimum of 6-8 nursing orders which are realistic, comprehensive, and individualized. Each order includes action verb, what, when, how, how much and frequency. Scientific rationale and references are included. 21 pts

2 CRITERIA Available Points Earned Nursing Orders: For each nursing order left out Orders not individualized No times or frequency/duration Inconsistent with goal/outcome criteria = -1 pt = -2 pts = -1 pt = -2 pts Each set of nursing orders is worth 7 pts 3. Rationale: If all ok If ½ right, ½ wrong If most or all wrong = +1 pt = -5 pt = 0 pt 3 pts Each set of rationale is worth 1 pt V. EVALUATION (10%) Evaluation refers to goal using the outcome criteria. Reassessment includes the entire plan of care VI. NEATNESS/GRAMMAR (5%) Clear and legible 5 pts 5 pts 2 pts Correct spelling, punctuation and structure 3 pts TOTAL 100 pts Points Subtracted for each day late -10/day Grade 100

3 CLINICAL NURSING III GRADED CARE PLAN PHYSICAL ASSESSMENT Student Name Initials Rm Age Gender Medical Diagnosis General Appearance Vital Signs HEENT Respiratory Cardio Gastrointestinal Genitourinary Musculoskeletal Integumentary Reproductive

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5 RNSG CARE OF CHILDREN & FAMILY Hospital Graded Care Plan Assessment Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure GROWTH AND DEVELOPMENT - AGES MONTHS Physical Gross Motor Fine Motor Sensory Vocalization Socialization/Cognition

6 RNSG CARE OF CHILDREN & FAMILY Hospital Graded Care Plan Assessment 6 Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure GROWTH AND DEVELOPMENT - TODDLER (15-30 Months) Physical Gross Motor Fine Motor Sensory Language Socialization (Zip3/RNSG 2262) 6

7 RNSG CARE OF CHILDREN & FAMILY Hospital Graded Care Plan Assessment 7 Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure GROWTH AND DEVELOPMENT - PRESCHOOLERS (Ages 3-5 Years) Physical Gross Motor Fine Motor Language Socialization Cognition Family Relationships (Zip3/RNSG 2262) 7

8 RNSG CARE OF CHILDREN & FAMILY Hospital Graded Care Plan Assessment 8 Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure GROWTH AND DEVELOPMENT - SCHOOL AGE (6-12 Years) Physical and Motor Mental Adaptive Personal/Social (Zip3/RNSG 2262) 8

9 RNSG CARE OF CHILDREN & FAMILY Hospital Graded Care Plan Assessment 9 Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure GROWTH AND DEVELOPMENT - ADOLESCENCE (11-20 Years) Growth Cognition Identity Relationships with Parents Relationships with Peers Sexuality Psychological Health (Zip3/RNSG 2262) 9

10 CLINICAL NURSING (R.N. TRADING) III PSYCHOLOGICAL-SOCIOLOGY-CULTURAL-COMMUNICATING ASSESSMENT For the GRADED CARE PLAN Student Name Pt. Initials Rm Gender Age Date(s) of care Medical Diagnosis and/or Surgical Procedure History of Present Illness Psychological Assessment Sociological and Cultural Assessment Reaction to Illness by Child and Significant Others Communication of Child and Significant Others (include verbal and non-verbal behavior, plus communication when interacting with peers, family members, or staff

11 PT. INITIALS AGE SEX DATE OF CARE: Diagnosis 11 ANALYSIS Nursing Diagnosis Priority Client Goal --Expected Outcomes (E.O.) Date Written The Format will be 1. P. Problem E. Etiology S. S&S (defining characteristics) 2. The phrase RELATED TO will be written between the P and E. (You may include secondary to) 3. The AS MANIFESTED BY AMB will be written between the E and S. 4. May use Actual, Risk for, and Wellness problems. 5. For Risk problems write only the Taxonomy (problem) and the Etiology (related to) 6. For Actual problems, write the defining characteristics (objective and subjective) that are present in the client/family. 1. Identify the priority for each problem using high, medium or low. 2. Indicate a specific rationale for each priority utilizing Maslows. 3. Assign a number to each priority. Example - High Priority life threatening according to Medium Priority: Explain why it is a medium priority Low: Give the rationale for assigning this low priority. Will include both the general goal and the specific expected outcomes. 1. CLIENT GOAL a. Reword or paraphrase the Problem. b. The goal must be written as a positive statement. c. The goal is a general, broad nonmeasurable statement. Example: The client will: as evidenced by: (AEB). Write the E.O. immediately after the AEB. 2. EXPECTED OUTCOMES - a. Remember Expected outcomes measure the goal attainment they are not interventions. b. Write at least three E.O. that are specific, measurable, individualized and realistic. (Note: RUMBA) R = Realistic U = Understandable M = Measurable B = Behavioral A = Attainable PLANNING AND IMPLEMENTATION Nursing Orders Rationale for Nursing Orders 1. The column will begin with the words The nurse will written at the top. 2. However, a specific individual may be identified. 3. Each order will contain: What--action verb (activity) How--conditions How much--when necessary Where-- When--identified by time or activity How often--identified by frequency (e.g. Q.3 hours starting at 0900) or by activity (e.g. TID after each meal) 4. Always include the independent actions of the nurse when utilizing doctors orders in the nursing care plan. 5. The column will end with the student s signature, date and time. The date is not necessary after each order. 1. To develop this area a reference or reference text is necessary 2. Sources must be cited. 3. Rationale should indicate specifically how and why a particular Nursing Order will assist in goal achievement. 4. Should be based on biological, psychological, sociological, cultural and communicating principles. (BPSCC) 7. NANDA nursing problems are preferred, but others can be used with valid data. c. Expected outcomes that are long-term may have a specific time and date. It is not necessary to write the date after each E.O. d. Date and time at bottom of column for overall goal. (Zip3/RNSG 2262) 11

12 12 EVALUATION Evaluate the Client Goal and Expected Outcomes Date of Evaluation 1. Evaluate the client s goal using one of the following phases Goal met Goal not met Goal partially met Goal in progress 2. Expected Outcomes Must include here evidence to support the conclusion for each E.O. Example: Goal partially met E.O. No. 1: Met because... E.O. No. 2: Not met due to the fact... E.O. No. 3: Met. The client stated 3 out of... REASSESSMENT Reassess the Entire Plan of Care, and Give Rationale for Additions, Deletions, or Continuation * NEW DATA: : Write new data that supports or alters Nsg. Dx. The new data should come from the assessment. (The statement, such as No New Data is not acceptable) NURSING DX Continue - Give rationale for continuing Discontinue - Give rationale for discontinuing Revise - Write the revision here such as changing from High to Actual GOAL Continue - Give rationale. Also remember to change the date Discontinue - Write here reasons for discontinuing the goal Revise - Write here the revisions, if needed Nursing Orders (N.O.) Example N.O. No. 1 Keep it because the client still needs to N.O. No. 2 Revise: Write the revisions and rationale here N.O. No. 3 Delete: It was unrealistic the client could not Change to: Write here the revision N.O. No. 4 Revise: The How and When they were omitted N.O. No. 5 Continue make no changes. Give rationale Add another N.O. to read NOTE: All revisions are made in the reassessment section. Examples: E.O. No. 1 Continue - Give rationale for keeping this O.C. E.O. No. 2 Delete due to... Explain why E.O. No. 3 Revise... Write here the change (Zip3/RNSG 2262) 12

13 Student Name: 13 PT. INITIALS AGE SEX DATE OF CARE: Diagnosis ANALYSIS Nursing Diagnosis #1 Priority Client Goal --Expected Outcomes (E.O.) Date Written PLANNING AND IMPLEMENTATION Nursing Orders Rationale for Nursing Orders (Zip3/RNSG 2262) 13

14 Student Name: 14 EVALUATION Evaluate the Client Goal and Expected Outcomes Date of Evaluation REASSESSMENT Reassess the Entire Plan of Care, and Give Rationale for Additions, Deletions, or Continuation * NEW DATA: Nursing Orders (N.O.) NURSING DX GOAL Student Name: (Zip3/RNSG 2262) 14

15 PT. INITIALS AGE SEX DATE OF CARE: Diagnosis 15 ANALYSIS Nursing Diagnosis #2 Priority Client Goal --Expected Outcomes (E.O.) Date Written PLANNING AND IMPLEMENTATION Nursing Orders Rationale for Nursing Orders (Zip3/RNSG 2262) 15

16 Student Name: 16 EVALUATION Evaluate the Client Goal and Expected Outcomes Date of Evaluation REASSESSMENT Reassess the Entire Plan of Care, and Give Rationale for Additions, Deletions, or Continuation * NEW DATA: Nursing Orders (N.O.) NURSING DX GOAL Student Name: (Zip3/RNSG 2262) 16

17 PT. INITIALS AGE SEX DATE OF CARE: Diagnosis 17 ANALYSIS Nursing Diagnosis #3 Priority Client Goal --Expected Outcomes (E.O.) Date Written PLANNING AND IMPLEMENTATION Nursing Orders Rationale for Nursing Orders (Zip3/RNSG 2262) 17

18 Student Name: 18 EVALUATION Evaluate the Client Goal and Expected Outcomes Date of Evaluation REASSESSMENT Reassess the Entire Plan of Care, and Give Rationale for Additions, Deletions, or Continuation * NEW DATA: Nursing Orders (N.O.) NURSING DX GOAL (Zip3/RNSG 2262) 18

19 19 (Zip3/RNSG 2262) 19