Introduction: Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. History: PMH Treatments admission Detailed and specific including all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Pathophysiology Disease process, cause and manifestations. Extensive detail with causes and manifestations. Comparing your patient to the classic presentation. Detailed with causes and manifestations & comparison of patient to classic presentation. Detailed but without causes or manifestations OR comparisons Detailed but without causes or manifestations and comparisons Not detailed and without causes, manifestations, and comparisons. Assessment: Complete Head to Toe OR Mental assessment. Detailed and specific assessment includes all aspects mentioned in guidelines. Detailed and specific, but missing one aspect mentioned. Detailed or Specific (not both) and/or missing 2 aspects mentioned Not detailed or specific and missing 1-2 aspects mentioned. Not detailed or specific and missing more than 3 aspects mentioned. Related Treatment: Discuss treatments DURING your care that are specific to the diagnosis. Detailed treatments specific to diagnosis, as well as other treatment/tests important to care. Detailed treatments specific to diagnosis. Detailed treatments not specific to the diagnosis. not identify relevant data Unable to identify treatment related to diagnosis or care. No related to treatment mentioned. Nursing Care: Nursing diagnoses with at least 3 interventions each. 3 or + with 3 interventions each and listed by prioritization. 3 or + either incorrectly prioritized, or with less than 3 interventions. 2 with 3 interventions each and listed by prioritization. 2 either incorrectly prioritized, or with less than 3 interventions. 1 or less diagnosis. Legal/Ethical: Legal/Ethical Issue. Actions taken (or should have been taken). Application of ANA Code of Detailed discussion of L/E Issue, actions taken (or should have been taken), and application of ANA Code of Detailed discussion of L/E without either actions taken or application of ANA Code of Ethics Detailed discussion of L/E Issue without actions taken or application of ANA Code of Ethics Issue addressed that is neither legal or ethical. Statement that no issue existed.
Ethics. Ethics. Cultural/Ethnic: Culture of pt (socioeconomics and/or ethnicity). Discuss specific cultural care. Health/healing traditions influencing health care. Detail culture of pt with specific cultural considerations. Discuss actual or possible traditions influencing care. Detail culture of pt including either cultural considerations or traditions influencing care. Detail culture of pt with no cultural considerations or traditions influencing care. Incorrectly identify cultural/ethnic considerations State there is no cultural/ethnic considerations for this patient. Teaching: Who to What to teach (content and method)? How to teach? Why teach? When to teach? Detailed teaching plan that answers all the questions. Detailed teaching plan that answers 4 of the questions. Detailed teaching plan that answers 3 of the questions. Detailed teaching plan that answers 2 of the questions. Detailed teaching plan that answers 1 of the questions. Or inappropriate teaching plan. Related Research: research articles related to the specific care of your patient 1 or more research articles summarized and applied to your patient. APA citation 1 research articles summarized and applied to your patient. No APA citation 1 research articles summarized and/or applied to your patient. APA citation 1 research articles summarized and/or applied to your patient. No APA citation 1 research articles not summarized or applied to your patient. Critical Thinking (presenter) Critical Thinking (audience) Add each topic score to find the total points earned ___________/(divide it by) 48 (total points possible) x 100 = __________ percentage earned Faculty comments and signature: Weekly Journal
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current psychotrophic meds?(After PMH, put the medication number that correlates with that illness; This should also include hospital meds) PMH: Home and Hospital Meds: Pharm. Classification: Expected Outcome: Side Effects 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 6. 7. 1. 2. 3. 4. 5. 6. 7. Nutrition Diet Height Weight BMI Snacks Nutritional Assessment (What are the nutritional needs for your patient based on his/her health status diagnoses; this may differ from the actual ordered diet)? Lab Results: (Complete for day before/most recent and then day of clinical) What lab results are RELEVANT that must be recognized as clinically significant to the Complete Blood Count (CBC:) Norms Mm/dd/yy Mm/dd/yy High/Low/WNL? WBC Hgb Platelets UDS TSH What lab results are that must be recognized clinically significant the nurse?
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Misc. Labs: Norms Date: Date: High/Low/WNL? Tegretol Glucose Valproic Acid HCG ASO Titer Other: RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Liver Function Test (LFT:) Norms Date: Date: High/Low/WNL? Albumin Bilirubin Alkaline Phosphatase ALT AST RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: