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Care Plan

Care Plan

Q Final Care Plan Based on your new patient assignment provided by your faculty develop a care plan. Use the care plan template in the course syllabus. You need to provide: • One NANDA approved nursing diagnosis based on the assessment data included in the care plan. • One short-term goal using the SMART guidelines • One long-term goal using the SMART guidelines • A minimum of 3 nursing interventions for each nursing diagnosis • Include scientific rationale for each nursing intervention • Cite source for rationale in APA format • Evaluate each goal Rubric ADN Care Plan 0619 ADN Care Plan 0619 Criteria Ratings Pts This criterion is linked to a Learning OutcomeAssessment and Medical History: • Is complete and accurate containing subjective and objective information related to the patient problem. PSLO 1, 2, 3 threshold: 15.0 pts 20 pts Includes all required data related to the patient’s problem. 15 pts Includes all pertinent data related to the assessment and the patient problem, but also includes data not related to nursing diagnosis. 10 pts Does not include accurate subjective and/or objective information related to the patient problem. 0 pts Assessment and Medical History competency was incomplete. 20 pts This criterion is linked to a Learning OutcomeDiagnosis - (view long description) The appropriate number of nursing diagnosis (NANDA approved); A diagnosis that correlates with the assessment data obtained; The “Related to” correlates with patient’s data collected in the assessment and is not a medical diagnosis; The “As evidenced by” correlates with the assessment data documented on the assessment form (only if actual diagnosis). PSLO 4, 5 threshold: 15.0 pts 20 pts The diagnosis is appropriate for the patient. The diagnosis is NANDA approved. The “Related to”, does correlated to the patient’s data and is not missing the elements. The “as evidenced”, does relate with the assessment and does have all elements under the right diagnosis. 15 pts The diagnosis is appropriate for the patient. The diagnosis is NANDA approved. There is a correlation to the patient’s data but it is missing some of the elements. The “as evidenced”, does relate with the assessment but does not have all elements under the right diagnosis. 10 pts The diagnosis is not appropriate for the patient. The diagnosis is not NANDA approved. There is no correlation to the patient’s data and the diagnosis does not have all the elements. The “as evidenced”, does not relate with the assessment and does not have all elements. 0 pts Diagnosis competency was incomplete. 20 pts This criterion is linked to a Learning OutcomePlanning (view longer description) 1 short-term and 1 long-term mutual goal; each goal is Related to nursing diagnosis; Patient centered; Realistic for patient situation; and Has a timeframe and is measurable. PSLO 1, 2, 3, 4, 5 threshold: 3.0 pts 20 pts The short term and long term goal was related to the nursing diagnosis. The Goal statement is patient or family oriented. The Goal statement is realistic and pertains to the Patient’s situation. The Goal statement contains all required measurable criteria or a targeted date/time. 15 pts The short term and long term goal was related to the nursing diagnosis. The Goal statement is patient or family oriented. The Goal statement is realistic and pertains to the Patient’s situation. The Goal statement contains at least one measurable criteria or a targeted date/time. 10 pts One short-term or one long-term goal was not related to the nursing diagnosis. The Goal statement is not patient or family oriented. The Goal statement is not realistic and does not pertain to the patient’s situation. The goal statement did not have measurable criteria or a target date or time. 0 pts The planning competency was incomplete. 20 pts This criterion is linked to a Learning OutcomeInterventions Minimum of three (3) nursing interventions for each nursing diagnosis (View longer description) Interventions Minimum of three (3) nursing interventions for each nursing diagnosis. Each intervention should: Contribute to the achievement of goals Be comprehensive Have scientific rationale Include documentation and references that are cited in APA format. PSLO 1,2,3,4,5 threshold: 15.0 pts 20 pts Met. The assigned number of interventions is met. The interventions contribute to the patient/family goal. The interventions are specific to the patient/family. The interventions are appropriate with rationale, include documentation and references in APA 15 pts Partially Met. The assigned number of interventions is met. The interventions contribute to the patient/family goal. The interventions are specific to the patient/family. The interventions may not include appropriate rationale, may not include documentation or lacking references in APA. 10 pts Needs Improvement - The assigned number of interventions is not met or interventions are met but the interventions do not contribute to the patient/family goal. The interventions are not specific to the patient/family, does not include appropriate rationale, may not include documentation or lacking references. 0 pts Not met. The Interventions Competency is incomplete. 20 pts This criterion is linked to a Learning OutcomeEvaluations (View longer description) Evaluate each short-term goal and state if goal was met, partially met, or not met; Must be patient-centered; Must provide evidence. PSLO 4, 6 threshold: 15.0 pts 20 pts The evaluation does describe the goal as met, partially met, or not met. The evaluation is patient/family centered. Evidence was provided. 15 pts The evaluation does describe the goal as met, partially met, or not met. The evaluation is patient/family centered. Evidence was not provided. 10 pts The evaluation does not describe the goal as met, partially met, or not met. The evaluation is not patient/family centered. Evidence was not provided. 0 pts The Evaluations competency is incomplete. 20 pts Total Points: 100 PreviousNext

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Assessment Data: Vital Signs: HR 78, BP 183/112, RR 14, SpO2 93% on room air and temperature 38.0?C General Appearance: Teary-eyed Cardiovascular: Normal sinus rhythm with systolic murmur Respiratory: Breath sounds with coarse crackles bilaterally GU: Voiding without difficulty Extremities: Pink and warm; pedal pulse to right foot is absent Skin: Pink, warm and dry; skin turgor good Neurological: Alert and oriented to person, place, and time; pupils equal and reactive to light and IVs: Saline lock in the right forearm Fall Risk: High risk for falls Pain: No complaints of pain Nursing Diagnosis: degenerative Osteoarthritis R/T (correlated to patient data): Degenerative hip As evidenced by (subjective/objective data): severe arthritis, unrelieved pain in her right hip