Prioritized Gordon’s Functional Health Care Patterns Nursing Diagnosis (at least 2) Planning (outcome/goal) Measureable goal during your shift (at 1 per Nursing diagnosis) PrioritizedIndependent and collaborative nursing interventions; include further assessment, intervention and teaching (at 4 per goal) Rationale (use APA citations) Evaluation Goal Met, partially met, or not Met & Explanation Current Medications 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 client
NURSING CARE PLAN RUBRIC NAME: COURSE: ________DATE: ________________ CLIENT INITIALS: CLIENT DISEASE/DISORDER: _____________________ Criteria 4 (Exceeds Expectations) 3 Expectations) 2 (Approaching Expectations) 1 (Does Not Meet Expectations) Weight History of Present Illness, Physical Assessment, & Diagnostic procedures □HPI explained in detail with accurate and understanding of chief complaint and presenting signs/symptoms supported by physical assessment; □ Identifies 5-6 key assessments parameters relevant to medical diagnoses with APA references. □HPI explained in some detail with moderate understanding of chief complaint and presenting signs/symptoms somewhat supported by physical assessment; □ Identifies 3-4 key assessments parameters relevant to medical diagnosis with references. □HPI explained in limited detail with marginal understanding of complaint and presenting signs/symptoms vaguely supported by physical assessment; □ Identifies 1-2 key assessments parameters relevant to medical diagnosis, no references cited. □HPI details limited with poor understanding of chief complaint and presenting signs/symptoms does not support medical diagnosis, □Identifies assessments parameters not relevant to medical diagnoses, no references cited. Past Medical & Surgical □Past medical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms. □APA references cited. □Past medical history with partial explanation of identified preexisting medical diagnoses& explanation accurate with some detail related to the client’s history and symptoms. □References cited □Past medical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms without references. □No past medical history given without explanation; no preexisting medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without references.
3. Erikson’s Developmental Stages & Socioeconomic/ Psychosocial Assessment □Identifies and defines correct with examples of meeting/not meeting tasks with APA references. Describes socioeconomic and cultural background in complete detail. □Identifies 3 psychosocial concerns □Identifies and defines correct with examples of meeting/not meeting tasks with references. DescribesSocioeconomic and cultural background in some detail. □Identifies 2 psychosocial concerns □Identifies correct stage without adequate definition or example of meeting/not meeting tasks without references. Describes Socioeconomic and cultural background in vague detail without references □Identifies 1 psychosocial concerns. □Identifies incorrect stage without definition or inappropriate examples given, no references. Describes socioeconomic and cultural background with no detail without references □Identifies no psychosocial concerns Interprofessional Consults & Discharge Referrals □Lists 3 or more appropriate collaborative issues/concerns □Rationale demonstrates excellent understanding of interventions □Lists 2 appropriate collaborative issues/concerns □Rationale demonstrates satisfactory understanding of interventions 1 appropriate collaborative issue/concern □Rationale demonstrates understanding of interventions inappropriate collaborative issues/concerns □Rationale demonstrates unsatisfactory understanding of interventions Potential Health Deviations □Identifies TWO prioritized risk factors according to NANDA format& identifies 3 signs and symptoms associated with the “at risk” diagnosis. □Writes 3 independent nursing interventions □Identifies 1 prioritized risk factor according to NANDA format& identifies 2 signs and symptoms associated with the “at risk” diagnosis □Writes 2 independent nursing interventions □Identifies 2 prioritized risk factors but not NANDA format& identifies 1 sign or symptom associated with the “at risk” diagnosis □Writes 1 independent pertinent intervention □Does not identify prioritized risk factors or signs & symptoms not identified or not related to “at risk” diagnosis □Writes 1 independent intervention not pertinent Gordon’s 11 Functional Health Care Patterns □Identifies 2 appropriate health care patterns □Identifies 1 appropriate health care patterns □Identifies 2 inappropriate health care patterns □Identify 1 inappropriate health care patterns
hospitalizations and surgeries understanding in relation to present health problem explanation and provides detailed history of previous hospitalizations and surgeries. explanation in relation to present health problem with some history provided for client’s previous hospitalization and surgeries explanation in relation to present health problem and previous hospitalization and any surgeries explanation in relation to present health problem With no history provided for previous hospitalization and surgeries 3. Family, Culture and Ethnic background Complete information provided client family, provides cultural point of view in illness and wellness and connects Ethnicity to health problems, APA references Some information provided client family and cultural point of view in illness and wellness, somewhat connects Ethnicity to health problems, with references Vague information provided about client family and cultural point of view in illness and wellness, vaguely connects Ethnicity to health problems, no references cited No information provided about client family and cultural point of view in illness and wellness, establishes no connect to Ethnicity and the health problems, no APA references SCALE 4 (Exceeds Expectations) 3 ( Expectations) 2 ( Approaching Expectations) 1 (Does not meet Expectations) CRITERIA 10 8 5 3 POINTS 4. Discharge Planning 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 5. Identify complications occurred with present medical diagnosis using priority assessments specific to patient’s status Complete information provided with present medical diagnoses priority assessment specific to patient’s status. Example stroke patient with priority assessment can identify paralysis as a complication or inability to swallow Some information provided with present medical diagnoses using priority assessment specific to patient’s status Vague information provided with present medical diagnosis using priority assessment specific to patient’s status No information provided with present medical diagnosis using priority assessment specific to patient’s status CRITERIA 5 3 2 1 POINTS 6. Use clinical & psychosocial assessment data to validate selection of nursing diagnoses Completely able to provide rationale for chosen nursing diagnosis using clinical and psychosocial assessment data Somewhat able to provide rationale for chosen nursing diagnosis clinical and psychosocial assessment data Vague in providing rationale for chosen nursing diagnosis using clinical and psychosocial assessment data Not able to provide rationale for chosen nursing diagnosis using clinical and psychosocial assessment data
CRITERIA 10 8 5 3 POINTS 7. Priority NANDA Nursing Diagnosis 1 at risk and 2 actual TWO actual nursing diagnoses written correctly per NANDA format with proper R/T and Evidence for actual Nursing diagnosis and R/T for at risk Nursing diagnosis Written correctly without sufficient data to support diagnosis Written incorrectly with sufficient data to support diagnosis Written incorrectly without sufficient data to support diagnosis 8.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 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 4 (Exceeds Expectations) 3 ( Meets Expectations) 2 ( Approaching Expectations) 1 (Does not meet Expectations) CRITERIA 10 8 5 3 POINTS 10. Medications Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug. Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug. 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. CRITERIA 5 4 3 1 POINTS 11. 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 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 TOTAL: COMMENTS:
SKILLS LAB COMPETENCY SKILLS RUBRIC Student Name: DATE: Skills To Be Tested: CRITERIA 4 (Exceeds Expectations) 3 ( Meets Expectations) 2 ( Approaching Expectations) 1 (Does not meet Expectations) Weight of Criteria Preparation of Client Performed critical elements of procedure. Needed no more than 0- 2 verbal cues by instructor. Demonstrated excellent preparation of client for procedure. Explained procedure satisfactorily. Provided privacy. Did perform safety checks Did critical steps, however needed more than 3-4 verbal cues to perform skill, some hesitation noted. Demonstrated good preparation of client for procedure. Explained procedure moderately. Provided privacy. Perform safety checks Needed several cues to perform procedure. Asking fellow students for assistance and hesitation noted. Demonstrated poor preparation of client for procedure. Explained procedure minimally. Provided privacy but did not perform safety Has no clue how to perform procedure. Did not demonstrate proper preparation of client. Did not explain procedure to be performed. Did not provide privacy. Did not performed safety checks on equipment X 2
Section B: Course Outline Week/Date Class Objectives Course Content Course Specific Activities Student Assignments Week 1 CLO# 1, 2, 6, 13,15, 16, 18, 20, 24, 25. Skills Lab: Verbalize understanding of university course requirements. Describe the health care industry and the nursing profession Identify models of nursing care delivery. Describe current nursing practice in of domain, definitions, and recipients of care. Describe the five phases of the nursing process. Identify the various practice available to nurses. Describe the roles and challenges of nurses working in community-based settings. Describe critical thinking, ethical decision making, and the nursing process Demonstrate proficiency with medication calculations. Demonstrate proper technique when starting an IV, and when administering IV medications. Clinical: Skills Lab/Clinical: Introduction to the course and objectives Gordon’s 11 functional conceptual framework. Use the nursing process, evidenced based practice, therapeutic communication, teaching/learning principles and role development as applied in the medical surgical setting. Core competencies for safe and effective health care. -QSEN patient safety initiative. -National Patient Safety Goals. Guidelines for nursing practice -Infection Control and Prevention -Hospital policies and procedures. - Clinical Decision-Making Skills for student nurse. Cognitive Mapping. Intravenous catheter insertion and management. Skills: Introduction for the course/Discussion of the syllabus and course expectations. Discuss Gordon’s 11 functional conceptual framework, definition of professional nursing, ANA Code of Ethics for Nurses, The Client Role, The Nurse Practice Act, QSEN initiatives, National Patient Safety Goals, Infection Control Review Nursing Process and Critical Thinking Skills Activities: Review of Medication Math video for medication/drug management Watch video for IV therapy and IV medication administration. Demonstration/Return Demonstration a. Medication administration- Oral, b. Parenteral (IM, SQ, ID) c. PIV catheter insertion Perry & Potter, Ch. 1, Ch. 8, Ch. 20, Ch. 21, Ch. 22, Ch. 28. Ch. 1, Ch. 2, Ch.3. Henke’s – Ch. 1-4, Pg. 1- 82. Video- ATI on line. CD\DVD’s from ATI. RN Student Handbook - Read entire student nurses handbook. Cognitive mapping- see computer CD for assistance in learning this skill. IV medication clinical simulation computer series. This must be completed within two weeks of the start of class and before student can administer any IV medications or start any IV’s. QSEN Website:
Clinical: Verbalize understanding of university course requirements, professional nursing, and specific clinical agency policies, procedures,regulations, and standards of care. Participate in general orientation to assigned clinical setting. Describe client’s rights, HIPPA, abuse reporting, national patient safety goals, QSEN patient safety initiatives, infection control and prevention standards. Intravenous PO, and Parenteral medication preparation, and administration Clinical: Agency clinical orientation. Adult IV training arm/hand Virtual IV Partner d. IV Medication Administration Clinical: Orientation to clinical setting. Initial nursing care to assigned client. Week 2 CLO# 1, 2, 5, 6, 7, 8, 10, 11, 12, 15, 17, 18, 19, 20, 23 d, h. Skills/Clinical: Consider the impact that a person’s gender, age, culture, and lifestyle have on the incidence of selected health problems. Identify strategies for incorporating cultural information in the nursing process when providing care for patients from different cultural and ethnic groups. Describe the importance of protecting the safety and privacy of patients in relation to the use of health Skills/Clinical: Gordon’s 11 functional conceptual framework. Use the nursing process, evidenced practice, therapeutic communication, teaching/learning principles and role development as applied in the medical surgical setting. HIPPA Guidelines Review of pharmacological therapy used in the acutely ill medical surgical patient with Pain, Regulatory, Ingestion, Digestion, Skills: Review Gordon’s 11 functional conceptual framework Review HIPPA, Pharmacological Therapy for Pain, Regulatory, Ingestion, Digestion, Absorption, and Elimination problems. Skills Activities: Watch Video/DVD/demonstration a. Central venous access management Perry & Potter, Ch. 28, Ch. 29, Ch. 43. ATI Content Mastery Series Pharmacology Section – Unit 4, 10, 11. ATI Content Mastery Series Fundamentals 6.0 - Section 7, 8, 9, 10, 11, 12, 14, 43, 44, 45, 46, 47, 63, 75, and 78. ATI online. Use CD\DVD’s to review understanding of content,
care and information technology. Assess one’s own learning needs and develops them to insure the best knowledge for patient care. Demonstrate competence in the ability to perform IV insertion and parental medications in a variety of clinical setting and modes of delivery. Describe importance of conducting specimen collection and phlebotomy. Verbalize understanding of importance of diagnostic procedures- Glucose monitoring Hemoccult test 3. Dipsticks Clinical: Demonstrate skill in using the nursing process according to Gordon’s 11 patterns of human functioning for adult client, their family, and their community. Recognizes hazards to client safety and takes appropriate action to maintain safe environment using “60 second assessment” and Absorption, and Elimination problems. Demonstrate competence in the ability to perform IV insertion and parental medications in a variety of clinical setting and modes of delivery. Care and medication administration through central vascular access devices. Specimen collection, phlebotomy. Diagnostic procedures- Glucose monitoring Hemoccult test Dipsticks b. Blood Transfusion/ Administration c. IVPB medication primary and secondary administration Care and medication administration through central vascular access devices. Specimen collection, phlebotomy. Diagnostic procedures- Glucose monitoring Hemoccult test 3. Dipsticks Demonstration/return demonstration-Group a. PIV insertion and care of site b. Care of central venous access. c. Blood Administration d. IV Piggyback medication administration. e. Blood Glucose monitoring f. Calculation of BMI and IBW. g. Hemoccult test h. Urine Dipstick bringquestions to class in preparation for the Medication math test- this must be passed with at least an 85% in order to pass medications and pass the class. (Clinical Med-Math Test, weekly Med-Math evaluation to be provided by Clinical Instructors in any format in clinical settings). IV competency Henke’s Med-Math Book: Ch. 1-6.
other clinical assessment tool. Maintains confidentiality of client information by adhering to HIPPA guidelines and complete HIPPA training with documentation. Provides care regardless of client social, economic, ethnic, and cultural health status through demonstration of culturally sensitive/competent care. Implements use of Standards Precautions, and techniques as appropriate to client situation. Demonstrate effective verbal, nonverbal, and therapeutic communication skills with the client and the interprofessional healthcare team. Speaks and writes in a professional manner. Participate in the collaborative and nursing management of patients with Oxygenation, Pain, Regulatory, and Ingestion, Digestion, Absorption, and Elimination problems. Demonstrate proficiency in beginning medical math Med Math Quiz Clinical: Pre/post Conference Nursing care on assigned client. Clinical Med Math
Week 4 CLO# 1, 2, 5, 6, 7, 8, 10, 11, 12, 15, 17, 18, 19, 20, 23 g, i, j, Skills Lab: Demonstrate competency when performing previously learned skills. Clinical: Demonstrate skill in using the nursing process according to Gordon’s 11 patterns of human functioning for adult client, their family, and their community. Recognizes hazards to client safety and takes appropriate action to maintain safe environment using “60 second assessment” and other clinical assessment tool. Maintains confidentiality of client information by adhering to HIPPA guidelines. Provides care regardless of client social, economic, ethnic, and cultural health status through demonstration of culturally sensitive/competent care. Implements use of Standards Precautions, and techniques as appropriate to client situation. Skills: Review and evaluation of skills to date. Clinical: ●Gordon’s 11 functional conceptual framework. Use the nursing process, evidenced based practice, therapeutic communication, teaching/learning principles and role development as applied in the medical- surgical setting. Review and provision of pharmacological therapy used in the acutely ill medical surgical patient with Oxygenation/ Ventilation Problem, Pain, Regulatory Problem (Diabetes Mellitus), Ingestion, Digestion, Absorption, and Elimination Problems, Movement, Coordination, Altered Sensory Input, and Skin Integrity (Pressure Ulcers/Wounds)Problems. Review six-rights of medication administration. Care Mapping/Nursing Care Plan. Skills Competency Testing Med-Math Clinical: Pre/post Conference Nursing care on assigned client. Clinical evaluation (formative) Nursing Care Plan/Map submission. Review/demonstrate/evaluate covered skills. Perry & Potter, Ch. 15, Ch. 23 – Ch. 26, 27, 28, 29, 45,46. ATI Content Mastery Series Pharmacology Section – Unit 1, 2, 4, 8, 9 ATI Content Mastery Series Fundamentals 6.0 - Section 25, 27, 28, 29, 35, 43, 44, 45, 46, 47, 55, 68, 69, 70, 73, 74, and 63. Video- ATI on line. Henke’s Med Math: Ch. 7
Describe teaching/learning principles in proving therapeutic nursing care to clients/patients in the preoperative and postoperative phase of care. Describe teaching/learning principles in proving therapeutic nursing care to clients/patients Oxygenation: Ventilation and Perfusion Problems. Describe or demonstrate use of various nursing procedures- Sitz bath CBI Incentive spirometer Chest Physiotherapy Post-op exercises Tracheostomy Care and Suctioning Chest –Tubes Principles/Nursing Care Clinical: Demonstrate skill in using the nursing process according to Gordon’s 11 patterns of human functioning for adult client, their family, and their community. Chest-Tube Principles and Nursing Care Clinical: Review and provision of pharmacological therapy used in the acutely ill medical surgical patient with Oxygenation/ Ventilation/Perfusion Problem, Pain, Review six-rights of medication administration. Preoperative Checklist. Demonstration/Return Clinical: Pre-post Conference Nursing care on assigned client.
12, 15, 17, 18, 19, 20, 23 e, g, l. competent health assessment for clients when planning their care. Describe or demonstrate an assessment for client with an eye and ear problem. Describe or demonstrate an assessment for a patient with nutritional and/or elimination problem. Describe or demonstrate appropriate technique when performing: ○Enteral feeding ○ Parenteral feeding Clinical Demonstrate skill in using the nursing process according to Gordon’s 11 patterns of human functioning for adult client, their family, and their community. Recognizes hazards to client safety and takes appropriate action to maintain safe environment using “60 second assessment” and other clinical assessment tool. Maintains confidentiality of client information by communication, teaching/learning principles and role development as applied in the medical surgical setting. Clinical: ●Review and provision of pharmacological therapy in acutely ill medical surgical patient with ○enteral ○ parenteral feeding needs. ○ ear and eyes disorder ● Nursing management of client with nutritional management and enteral intubations. ● Nursing management of client with nutritional management and parenteral nutrition. ●Nursing management of client with visual and auditory problems. Enema Administration volume enema, small volume enema, return flow enema Enteral Feeding Parenteral Feeding Demonstration/Return Demonstration Medication Math Clinical: Pre-post Conference Nursing care on assigned client. Nursing Care Map ATI Content Mastery Series Pharmacology Section – Unit 1, 2, 4, 5, 6, 8, 10. ATI Content Mastery Series Fundamentals 6.0 - Section 27, 28, 29, 32, 33, 37, 43, 44, 45, 46, 47, 55, and 53. ATI online. Henke’s – Ch. 9.
Utilize systematic collection of data, physical assessment techniques, and appropriate documentation on individual client needs. Participate in the collaborative and nursing management of patients with eye and ear problem and client with enteral and/or parenteral feeding needs. Week 7 CLO# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 17, 18, 19, 20, 23 h, i. Skills Lab/Clinical: Demonstrate knowledge of the nursing process, therapeutic care and other strategies to provide competent health assessment for patients when planning their care. Describe or demonstrate an assessment for a patient with a gastrointestinal and genitourinary problem. Describe or demonstrate an assessment for a patient with Fluid and Electrolyte balance disorder to include acid -base balance, fluid volume deficit or excess, and hypo and hyper disorders of electrolytes. Skills Lab: Gordon’s 11 functional conceptual framework. Use the nursing process, evidenced practice, therapeutic communication, teaching/learning principles and role development as applied in the medical surgical setting. Gastrointestinal and genitourinary problem to include : ○ Intake and Output ○ Enemas ○ Ostomy care Fluid and Electrolyte balance disorder to include acid -base balance, fluid volume deficit or Skills Activities: Watch Video/DVD/Demonstrate/ Genitourinary/ Gastrointestinal (abdominal) assessment. Observation/Inspection Auscultation Palpation Percussion Demonstration: Intake and Output Urine Collection – Open and Closed System. Suprapubic Catherter Care Nasogastic Feeding/Care Parenteral Feeding (TPN) Management of Percutaneous gastrostomy Tube Perry & Potter, Ch. 6, Ch. 31, Ch. 32, Ch. 33, Ch. 35. Lewis - Ch. 17, 43, and 46. ATI Content Mastery Series Pharmacology Section – Unit 1, 6, 9, 10. ATI Content Mastery Series Fundamentals 6.0 - Section 27, 28, 29, 73, 74, 78, and 79. - ATI online. Henke’s – Ch. 10.
experiencing medical surgical problems. Describe or demonstrate an assessment for a client with neurological impairment. ○ Glasgow Coma Scale ○ Mini-mental Examination. ○ DTRs ○ Motor Function Clinical: Demonstrate skill in using the nursing process according to Gordon’s 11 patterns of human functioning for adult client, their family, and their community. Recognizes hazards to client safety and appropriate action to maintain safe environment using “60 second assessment” and other clinical assessment tool. Maintains confidentiality of client information by adhering to HIPPA guidelines. Provides care regardless of client social, economic, ethnic, and cultural health status through demonstration of culturally sensitive/competent care. Review of course materials. Instructor to review key concepts in class, answer questions and help with skills test taking strategies. Clinical: ● Gordon’s 11 functional conceptual framework. Use the nursing process, evidenced based practice, therapeutic communication, teaching/ learning principles and role development as applied in the medical- surgical setting. Review and provision of pharmacological therapy used in the acutely ill medical surgical patient with neurological involvement. Review six-rights of medication administration. missed on exams until you reach 90%. The ATI Med Surg exam may have content that has not yet been covered in class. Review what you have missed for learning purposes.