History of present illness example nursing

Course Number and Name

Course: NURS 210L-AB

NURSING CARE PLAN RUBRIC

NURS 101L, NURS 210L-AB, NURS 317L

STUDENT NAME: COURSE: DATE:

PATIENT INITIALS: ___________ PATIENT DISEASE/DISORDER:

Criteria

4

Exceeds Expectations

3

Meets Expectations

2

Approaching Expectations

1-0

Does Not Meet Expectations

Score

History of Present Illness

HPI explained in detail with accurate and in-depth understanding of chief complaint and supported by evidence based citations.

HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations.

HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations.

HPI details limited with poor understanding of chief complaint and no evidence based citations to support.

X2

Physical Assessment, & Diagnostic tests/ procedures

Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations.

Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations.

Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations.

Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations.

X2

Past Medical &

Surgical History, Pathophysiology

Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and supported by evidence based citations.

Past medical/surgical history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations.

Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations.

No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence.

X2

Erikson’s

Developmental Stages

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations.

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations.

Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations.

Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations.

X2

Socioeconomic/ Psychosocial Assessment

Describes socioeconomic and cultural background in complete detail with references; Identifies 3 psychosocial concerns.

Describes socioeconomic and cultural background in some detail with references; Identifies 2 psychosocial concerns.

Describes socioeconomic and cultural background in vague detail without references; Identifies 1 psychosocial concern.

Describes socioeconomic and cultural background

with no detail without references; Identifies no psychosocial concerns.

X1

Interprofessional

Consults & Discharge

Referrals

Lists 3 or more appropriate collaborative issues/concerns; Rationale demonstrates excellent understanding of consults and interventions.

Lists 2 appropriate collaborative issues/concerns; Rationale demonstrates satisfactory

understanding of consults and interventions.

Lists 1 appropriate collaborative issue/concern; Rationale demonstrates vague understanding of consults and interventions.

Lists inappropriate collaborative issues/concerns; Rationale demonstrates unsatisfactory

understanding of consults and interventions.

X2

Potential Health

Deviations

Identifies TWO prioritized risk factors in proper format; Writes 3 independent nursing interventions.

Identifies 1 prioritized risk factor in proper format; Writes 2 independent nursing interventions.

Identifies 2 prioritized risk factors but not in proper format; Writes 1 independent pertinent nursing intervention.

Does not identify prioritized risk factors; Writes 0-1 independent nursing intervention not pertinent to the diagnosis.

X3

Priority

Nursing Diagnosis

TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis.

One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis.

Written incorrectly with sufficient data to support diagnosis, not a priority.

Written incorrectly, not in correct format, or without sufficient data to support diagnosis.

X4

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.

X2

Implementation and

Rationale

Identifies 4 independent interventions with teaching; Each is supported with scientific rationale using textbook or evidence based citations.

Identifies 3 independent interventions with teaching; Scientific rationale is supported with scientific rationale using textbook or evidence based citations.

Identifies 2 independent interventions with teaching; Scientific rationale is vaguely relevant & not supported from textbook.

Identifies 1 independent interventions with teaching; Scientific rationale is not relevant & not supported from textbook.

X2

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.

X2

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.

X1

Total

/100 %

COMMENTS:

FACULTY SIGNATURE: DATE: