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iRubric: Nursing Care Plan Rubric

iRubric: Nursing Care Plan Rubric

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Nursing Care Plan Rubric

  Derived from rubric: Nursing Care Plan Rubric
built by cheid1

Rubric Code: G8839X
Choose a patient scenario. It may be a patient you had in clinical, a patient with a disease or disorder of your choosing (different from the one presented in patho), or your instructor can provide one for you. Prepare a care plan based on relevant objective and subjective assessment data. Explain what assessments would be done and how data would be obtained. The care plan will include nursing diagnosis, written in proper format and listed in order of priority for care, planning and goal statements which must be attainable and measureable, nursing interventions with researched rationales (reference sources will be included for each rationale), and methods and expectations for evaluation including what would constitute the goals being met, partially met, or unmet. Please make your instructor aware of what patient scenario you have chosen by Fraiday, March 16/12. The care plan should be completed and handed in before midnight on Thursday, March 22/12
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Keywords: Nursing, Care Plan
Categories: Subjects: Nursing  
Types: Assignment  
Grade Levels: Undergraduate

Powered by iRubric Nursing Care Plan Rubric
Grading Criteria
  Incomplete
5 pts
Poor
10 pts
Fair
15 pts
Good
20 pts
Assessment
Includes subjective, objective and historical data that support nursing diagnosis.
Incomplete

Assessment portion is incomplete or inacurate.
Poor

Assessment data is not well organized. Subjective and objective data are not identified. Assessment data is irrelevant or does not support nursing diagnosis.
Fair

Identifies some significant, acurate and relevant data from more than one source. Does not consistently identify subjective and objective data correctly. Most assessment data supports nursing diagnosis.
Good

Utilizes multiple sources for data. Correctly identifies subjective and objective data which is clear, specific, and relevant. All data is clustered in a coherent manner and is related to a nursing diagnosis.
Diagnosis
Relevant NANDA approved diagnosis written in proper form (includes stem, related to or R/T, and as evidenced or AEB)
Incomplete

Diagnosis portion is incomplete or irrelevant.
Poor

Diagnosis are not NANDA approved, appropriate for patient or not prioritized. Diagnosis not clearly supported by assessment data.
Fair

One or two diagnosis are identified that are appropriate for patient and are NANDA approved and clearly supported by assessment data. May not be listed in order of priority, or lack the proper format.
Good

Three or more diagnosis are identified and are clearly supported by assessment data, and reflect accurate clinical judgement. They are appropriate for patient, well prioritized, NANDA approved, and written in correct format.
Planning (Goal Setting)
Includes patient/ family short term and long term goals based on the nursing diagnosis. Goals must be patient focused, realistic, and have clear measurable criteria with a target date/ time.
Incomplete

Goal portion is incomplete or completely unrelated to nursing diagnoses.
Poor

Goal statement are not relevant to nursing diagnosisis. Outcomes are consistently not client centered, measurable or have achievable target dates.
Fair

Goal statements are identified that relate to the nursing diagnosis, and are patient focused. Criteria for measurement included but may not be clear or contain realistic time frame for evaluation.
Good

Short and long term goals are identified that clearly relate to the nursing diagnosis, are written in a patient focused manner, and are realistic. Each goal contains clear criteria for measurement and a time frame for evaluation.
Implementation
Nursing interventions or actions that directly relate to the etiology of the nursing diagnosis and the patient goal and desired outcome. Each intervention must include referenced rationale (including source and page number if applicable).
Incomplete

Interventions portion is incomplete, not relevant to patient, or no rationales provided.
Poor

Interventions are unclear or do not clearly focus on the etiology of the nursing diagnosis or relate to patient goal outcomes.
Rationales provided do not demonstrate an understanding of the purpose of the interventions or no references are provided.
Fair

Identifies three or less interventions for each goal that relate to the etiology of the nursing diagnosis. Not all interventions may be specific. Rationales included but may be weak, or references are incomplete or from sources that may not be reliable.
Good

Identifies at least 3-5 specific interventions for each outcome criteria in order to help the patient/family reach the desired goal. Interventions are specific in action and frequency, and include rationales which are researched and clearly referenced with very reliable sources.
Evaluation
Outlines the methods to be used in evaluating outcome criteria, expectations for goals being met, and what would determine that the goal is met, partially met, or unmet. Explain how the plan of care would be revised or continued in each case including a new realistic evaluation date/time.
Incomplete

Evaluations portion is incomplete or does not relate to diagnosis, goal statement or interventions.
Poor

Evaluation portion does not consistently contain data that is listed as criteria in goal statement. May also not describe goal as met, partially met, or not met. May also not include revision or new evaluation date/time.
Fair

Clearly states how each outcome would be evaluated. Able to correctly identify criteria for goal being met, partially met, or unmet. Identifies revisions for careplan but may not include acurate rationale for revision or references may be from sources that may not be reliable, or a new date is not provided for reevaluation.
Good

Evaluation portion contains data that is listed as criteria in goal statement and lists expectations for meeting the goal. Clear explanation of the criteria for goals being met, partially met, or not met. Includes plan for continuation or revision, clearly referenced rationale for revisions from reliable sources, and a new evaluation date/time.



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