iRubric: Everest School of Nursing Care Plan rubric

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Everest School of Nursing Care Plan

Rubric Code: L78458

By mebrune

Ready to use

Public Rubric

Subject: Nursing

Type: Assignment

Grade Levels: Undergraduate

Category Enter rubric description
	Unsafe/Did not complete failure in meeting any/all minimal standards for safe practice. 0 pts	Unsatisfactory Inconsistent in meeting clinical objectives 76.99% or less of the time—inconsistent in meeting any/all minimal standards for safe practice, 1 pts	Minimal With ongoing guidance is able to meet all clinical objectives 77-82% of the time--Meets minimal standards for safe practice. 2 pts	Good With limited guidance is able to meet all clinical objectives 83-91% of the time. 3 pts	Outstanding Consistently, skillfully, and with early and progressive independence is able to meet all objectives (92-100% of the time. 4 pts
Assessment SimChart: PreClinical Manager, Patient Charting, Vital Signs, Patient Data, CarePlan
Assessment (#2) 1 pts Collects and interprets all pertinent laboratory data and diagnostic test results	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Lab data and diagnostic test results may or may not be recorded. Significant omissions are noted that could lead to a negative impact on patient outcome.	Minimal Some pertinent lab data and diagnostic test results are recorded. Most data that is irrelevant may be recorded but does not negatively impact patient outcome. Absence of pertinent data is not explained.	Good Most pertinent lab data and diagnostic test results are recorded. Some data that is irrelevant may be recorded but does not negatively impact patient outcome. Most data recorded helps to confirm, clarify and direct patient care.	Outstanding Pertinent lab data and diagnostic test results are recorded. Analysis of data recorded helps to confirm, clarify and direct patient care and is incorporated into the plan of care.
Assessment (#3) 1 pts Includes objective and subjective data as appropriate (Physiological, psychosocial, developmental, cultural, spiritual).	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Some subjective and objective data is collected. Blank spaces in the form are not explained. There is an absence of the use of inquiry to collect information relevant to the individual's disease and circumstances.	Minimal Some subjective and objective data is collected. Blank spaces in the form are not explained adequately. There is incomplete use of inquiry to collect information.	Good Most subjective and objective data is collected and is recorded using the appropriate terminology. Any data that that is not collected is adequately explained in the blank spaces. Additional data is collected through the use of inquiry most of the time, applying basic knowledge about the individual's disease and the patient's circumstances.	Outstanding All subjective and objective data is collected and is recorded using the appropriate terminology. Any data that is not collected is adequately explained in the blank spaces. Additional data is collected through the use of inquiry flawlessly, applying knowledge about the individual's disease and the patient's circumstances.
Assessment (#4) 1 pts Collects a holistic database on the adult client and family.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Some of Sim Cart documentation was completed. Very little accuracy and detail. with ommission of pertinent information.	Minimal Some of Sim Cart documentation was completed and with accuracy. There is some ommission of information. Data collected had some detail.	Good Most of Sim Cart documentation was completed throughly and with accuracy. There is no ommission of information. Detailed data collected and submitted in the database.	Outstanding All of Sim Cart documentation was completed throughly and with accuracy. There is no ommission of information. Detailed data collected and submitted in the database.
Assessment (#5) 1 pts Obtains a thorough medication record of the M/S client.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Obtains some current medications but no effort to interpret medication (indications, SE, Nursing Implications) was performed resulting in a flawed plan of care.	Minimal Obtains some of the current medications and minimally describes rationale for the specific medication order(s). The student identifies some potential problems and teaching needs individualized to the patient being cared for that is incorporated into the plan of care. Minimal effort to interpret medication (indications, SE, Nursing Implications) was performed resulting in a flawed plan of care.	Good Obtains most of the current medications and adequately describes rationale for the specific medication order(s). The information is complete. The student identifies potential problems and teaching needs individualized to the patient being cared for that is incorporated into the plan of care.	Outstanding Obtains all current medications and accurately describes rationale for the specific medication order(s). The information is complete. The student identifies potential problems and teaching needs individualized to the patient being cared for that is incorporated into the plan of care.
Nursing Diagnosis Care Plan
Diagnosis (#1) 1 pts Are derived from assessment data and prioritized based on the patient/client’s needs/condition according to a theoretical framework.	Unsafe/Did not complete The nursing diagnoses selected reflect that no effort to interpret information was applied resulting in a flawed plan of care.	Unsatisfactory The nursing diagnoses selected reflect that no effort to interpret information was applied resulting in a flawed plan of care.	Minimal The nursing diagnoses selected reflect the inadequate interpretation of the subjective and objective data analyzed and result in a flawed plan of care.	Good The nursing diagnoses selected reflect the adequate interpretation of the subjective and objective data analyzed but are not always the best choice from the possible diagnoses that could be interpreted from the data.	Outstanding The nursing diagnoses/problems selected reflect the accurate interpretation of the subjective and objective data analyzed. Subjective and objective data are listed appropriately as supporting data for the nursing diagnosis. All nursing diagnoses use NANDA terminology.
Plan of Care Care Plan, Specialty Charts, Nurses Notes
Plan of Care (#1) 1 pts Is derived from the diagnoses and establishes priorities.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory The nursing diagnoses are evaluated individually against a framework that does not facilitate prioritization of nursing diagnoses.	Minimal The nursing diagnoses are evaluated individually and are ranked in a priority order that indicates flawed decision making.	Good The nursing diagnoses are evaluated individually and are ranked in priority order and reflect a significant amount of coordination of care appropriate to the patient.	Outstanding The nursing diagnoses are evaluated individually and are ranked in priority order to best reflect the coordination of care appropriate to the patient.
Plan of Care (#3) 1 pts Utilizes therapeutic nursing interventions when providing care to adult clients and their families	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Interventions developed are incomplete. Inappropriate interventions may be included in the plan of care.	Minimal Interventions developed can be linked to specific outcomes but may be independent. The interventions may not be realistic and appropriate to the patient's current status.	Good Specific interventions can be linked to specific outcomes. The interventions are realistic and usually appropriate to the patient's current status.	Outstanding Specific interventions can easily be linked to specific outcomes. The interventions are realistic and appropriate to the patient's current status
Plan of Care (#6) 1 pts Is documented according to practice setting and specialty area	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Plan of care is documented but missing pertinent informtation as it pertains to the specialty area.	Minimal Plan of care is documented approptiratly (inclusive of some pertinent details) as it pertains to the specialty area.	Good Plan of care is documented adequately and accurately (inclusive of most pertinent details) as it pertains to the specialty area.	Outstanding Plan of care is documented approptiratly and accurately (inclusive of all pertinent details) as it pertains to the specialty area.
Expected Outcomes Care Plan
Outcomes (#1) 1 pts Outcomes are realistic in relation to patient/client's condition.	Unsafe/Did not complete The expected outcome selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Unsatisfactory The expected outcome(s) selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Minimal The expected outcome(s) reflects inadequate interpretation of the ND and NI.	Good The expected outcome(s) reflects adequate interpretation of the ND and NI.	Outstanding The expected outcome(s) reflects the accurate interpretation of the ND and NI.
Outcome (#2) 1 pts Outcomes are attainable in relation to available resources.	Unsafe/Did not complete The expected outcome selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Unsatisfactory The expected outcome(s) selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Minimal The expected outcome(s) reflects inadequate interpretation of the ND and NI.	Good The expected outcome(s) reflects adequate interpretation of the ND and NI.	Outstanding The expected outcome(s) reflects the accurate interpretation of the ND and NI.
Outcome (#3) 1 pts Include a time frame and/or an amount estimate.	Unsafe/Did not complete The expected outcome selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Unsatisfactory The expected outcome(s) selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Minimal The expected outcome(s) reflects inadequate interpretation of the ND and NI.	Good The expected outcome(s) reflects adequate interpretation of the ND and NI.	Outstanding The expected outcome(s) reflects the accurate interpretation of the ND and NI.
Outcome (#4) 1 pts Goals are measurable and appropriate for the patient.	Unsafe/Did not complete The expected outcome selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Unsatisfactory The expected outcome(s) selected reflects that no effort to interpret information was applied resulting in a flawed plan of care.	Minimal The expected outcome(s) reflects inadequate interpretation of the ND and NI.	Good The expected outcome(s) reflects adequate interpretation of the ND and NI.	Outstanding The expected outcome(s) reflects the accurate interpretation of the ND and NI.
Implementation/Intervention Care Plan, Patient Charting
Implementation/Intervention (#1) 1 pts Are consistent with the plan of care, expected outcomes and supported by EBP.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Interventions developed are incomplete. Inappropriate interventions may be included in the plan of care.	Minimal Interventions developed can be linked to specific outcomes but may be independent. The interventions may not be realistic and appropriate to the patient's current status.	Good Specific interventions can be linked to specific outcomes. The interventions are realistic and usually appropriate to the patient's current status.	Outstanding Specific interventions can easily be linked to specific outcomes. The interventions are realistic and appropriate to the patient's current status.
Implementation/Intervention (#5) 1 pts Are documented according to practice setting and specialty area.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Lists at least 1-2 nursing interventions to implement for the specific nursing diagnosis. Selected interventions reflect that no effort to interpret information was applied resulting in flawed plan of care.	Minimal Lists at least 2 nursing interventions to implement for the specific nursing diagnosis. Some interventions are specific and relevant to nursing specialty area.	Good Lists at least 3 nursing interventions to implement for the specific nursing diagnosis. Most interventions are specific and relevant to nursing specialty area.	Outstanding Lists at least 4 nursing interventions to implement for the specific nursing diagnosis. All interventions are specific and relevant to nursing specialty area.
Evaluation Care Plan, Nurses Notes, Patient Charting
Evaluation (#1) 1 pts Appropriately documents patient/client responses to interventions.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Subjective and objective data is selected to reflect evaluation without consideration of the outcome criteria. Subjective and objective data may or may not be collected. Data collection is not subjected to analysis.	Minimal The appropriate subjective and objective data is selected some of the time, perhaps through review of the interventions related to ongoing assessment or perhaps the data was collected coincidentally. Subjective and objective data is collected most of the time, but there appears to be no pattern to the data collection and it is rarely with consideration of the outcomes that are required to be measured.	Good The appropriate subjective and objective data is selected most of the time, through review of the interventions related to ongoing assessment that reflects adequate analysis.	Outstanding The appropriate subjective and objective data is selected through review of the interventions related to ongoing assessment. The subjective and objective data that measures the outcome is collected and analyzed correctly.
Evaluation (#2) 1 pts Is utilized to revise diagnoses, plan of care, and outcomes as necessary	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory Subjective and objective data is selected to reflect evaluation without consideration of the outcome criteria. Subjective and objective data may or may not be collected. Data collection is not subjected to analysis.	Minimal The appropriate subjective and objective data is selected some of the time, perhaps through review of the interventions related to ongoing assessment or perhaps the data was collected coincidentally. Subjective and objective data is collected most of the time, but there appears to be no pattern to the data collection and it is rarely with consideration of the outcomes that are required to be measured.	Good The appropriate subjective and objective data is selected most of the time, through review of the interventions related to ongoing assessment that reflects adequate analysis.	Outstanding The appropriate subjective and objective data is selected through review of the interventions related to ongoing assessment. The subjective and objective data that measures the outcome is collected and analyzed correctly.
Research/Quality of Care Nursing Notes
Research/Quality of Care (#1) 1 pts Utilizes the best availabe evidence, preferably practice guidelines based on research data, to provide care and support the plan of care.	Unsafe/Did not complete Failure in meeting any/all minimal standards for safe practice. Student did not complete.	Unsatisfactory References are recorded in the appropriate space. References are omitted/limited or irrelevant to aid the student's attainment of the appropriate knowledge to guide the plan of care.	Minimal References are recorded in the appropriate space. References reflect the student's inability to identify resources that can provide the appropriate knowledge to guide the plan of care.	Good References are recorded in the appropriate space. References reflect the student's pursuit of the basic knowledge in preparing the plan of care for the patient.	Outstanding References are recorded in the appropriate space. Varied and appropriate references reflect the student's pursuit of the best knowledge in preparing the plan of care for the patient. APA format is used to list references.

Subjects:

Nursing

Types:

Assignment

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