Individual Care Map Evaluation Tool



Individual Care Map Evaluation Tool – NSG240/315/ 350/430
Name: _______________________ Date: ___________ Patient’s initials: _______________

Concept

240/315/ 350/430

(Follow instructions provided and on Moodle)

The student will:

Maxi-mum Points/

Prepare: Concept Map and Written Analysis to plan care for a clinical patient:

Student points

Unsatisfactory

Basic

Satisfactory

Exceeds expectations

Comments:

Conduct and describe a thorough history and physical (Medical diagnosis, Lab and diagnostic tests, physician’s orders, Nursing physical assessment)

History and physical with many errors and components not addressed. (2 pts)

Partially conducts and describes history and physical with <80% accuracy. (5 pts) Conducts and describes thorough history and physical. 80-90% components accurate and complete. (8 pts) Conducts and describes thorough history and physical. 90-100% components complete and individualized to patient. (10 pts) Prepare: a table describing the pharmacotherapies: Medication, dose, frequency, route, class, top 3 side effects, indications Table of pharmacologic interventions with many errors of omission and content accuracy. (2 pts) Prepares a partially complete table of pharmacologic interventions with <80% accurate content. (5 pts) Prepares a complete and accurate table of pharmacologic interventions. (8 pts) Prepares a complete and accurate table of pharmacologic interventions. Indications are individualized for the patient. (10 pts) Demonstrate appropriate use of Gordon's Functional Patterns (GP) by organizing data into meaningful data clusters to determine associated nursing diagnosis (NDx). Data disorganized; GP not identified or not with appropriate data clusters; NDx do not reflect understanding of client problems. (1 pt) 60-80% of data organized and clustered; <80% of GP supported; NDx partially reflects understanding of client needs. (2 pts) 80-90% of data organized and clustered; 80-90% of GP identified with supportive data clusters; NDx identified reflect understanding of client problems. (4 pts) All data organized and clustered to represent 90-100% of Gordon's functional patterns; associated NDx identified reflect understanding of client problems. (5 pts) List at least 3 Nursing Diagnoses (NDx) based upon analysis of the data (must have at least 1 actual physiological, 1 psychosocial, and 1 educational nursing diagnosis clearly identified). All identified NDx listed from highest priority to lowest priority. Methods of prioritization of the nursing diagnoses discussed and diagram of prioritization process provided. Does not have required number or types of NDx; NDx not written in correct format; NDx not listed from highest to lowest priority. Or, Method of prioritization not discussed.(2 pts) ≤ 3 NDx listed based upon analysis of the data; does not include at least 1 actual physiological, 1 psychosocial, and 1 educational NDx; < 80% of NDx statements reflect correct formatting; <80% identified NDx listed from highest priority to lowest priority. Method of prioritization not met. (5 pts) 3 NDx listed based upon analysis of the data; includes at least 1 actual physiological, 1 psychosocial, and 1 educational NDx; All parts of the NDx statements reflect correct formatting; All identified NDx listed from highest priority to lowest priority. 80-90% of prioritization discussed. (8pts) 4 (four) or more NDx listed based upon analysis of the data; includes at least 1 actual physiological, 1 psychosocial, and 1 educational NDx; All parts of the NDx statements reflect correct formatting; All identified nursing diagnoses listed from highest priority to lowest priority (discussed). (10 pts) Answer the required questions in a separate document by Explaining the data to identify the human responses to a given health situation and determine the priority client needs based upon clusters of relevant data and Gordon’s Patterns. Questions that must be answered are provided in the instructions and are required as the header for each section. Does not explain components of the care planning process; Components missing; Methods of prioritization not discussed. (2 pts) Explanation of components of care planning process partially met; Questions head each section; Diagrams are missing or do not add to the planning process. (5 pts) Provides detailed and insightful explanation of 80-90% of components of care planning process; Questions head each section; Diagrams are easily understood and support. (8 pts) Provides detailed and insightful explanation of all components of care planning process; Questions head each section; Diagrams are easily understood and support. Care plan individualized for the patient. (10 pts) Demonstrate appropriate use of nursing process: Select and prepare a plan of care for the patient's priority Physiological NDx identified. All components included: • NDx with all relevant data; • Patient-centered goal (measurable and timeframe); • Patient-centered expected outcomes in SMART format; • 4 or more nursing interventions with evidence based (EBP) rationale and citation; • Evaluation of interventions and whether met/unmet/partially met with plan for revision. Does not reflect priority physiological NDx. Components of nursing process with incomplete or inaccurate information. Does not demonstrate appropriate use of nursing process. (5 pts) Priority physiological NDx correctly identified. < 80%% of components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes; 3 or more interventions selected. (12 pts) Priority physiological NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes showing goal achievement; 4 or more individualized interventions selected. (16 pts) Priority physiological NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 5 or more individualized interventions selected. (20 pts) Demonstrate appropriate use of nursing process: Select and prepare a plan of care for the patient's priority Psychosocial NDx identified. All components included: • NDx with all relevant data; • Patient-centered goal (measurable and timeframe); • 2 Patient-centered expected outcomes in SMART format; • 4 or more nursing interventions with evidence based (EBP) rationale and citation; • Evaluation of interventions and whether met/unmet/partially met with plan for revision. Does not reflect priority psychosocial NDx. Components of nursing process with incomplete or inaccurate information. Does not demonstrate appropriate use of nursing process. (5 pts) Priority psychosocial NDx correctly identified. < 80% of components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes; 3 or more interventions selected without evidence-based rationale. (12pts) Priority psychosocial NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes showing goal achievement; 4 or more individualized interventions selected. (16 pts) Priority psychosocial NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 3 or more expected outcomes showing goal achievement; 5 or more individualized interventions selected. (20pts) NSG 315, 350, 430 only: Demonstrate appropriate use of nursing process: Select and prepare a plan of care for the patient's priority Educational NDx identified. All components included: • NDx with all relevant data; • Patient-centered goal (measurable and timeframe); • Patient-centered expected outcomes in SMART format; • 4 or more nursing interventions with evidence based (EBP) rationale and citation; • Evaluation of interventions and whether met/unmet/partially met with plan for revision. Does not reflect priority educational NDx. Components of nursing process with incomplete or inaccurate information. Does not demonstrate appropriate use of nursing process. (5 pts) Priority educational NDx correctly identified. < 80% of components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes; 3 or more interventions selected without evidence-based rationale. (12 pts) Priority educational NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 2 or more expected outcomes showing goal achievement; 4 or more individualized interventions selected. (16 pts) Priority educational NDx correctly identified. All components of nursing process present on the care map with complete and accurate information. 3 or more expected outcomes showing goal achievement; 5 or more individualized interventions selected. (20pts) Use Care Map to Cluster and Analyze Data Create and format a client care map relevant to the patient's presenting problems. Data clusters disorganized and does not show critical thinking leading to identification of human response to the situation. Relationships between concepts with Care Map format poorly indicated. (2pts) Non-patient-centered care map developed. All components of nursing process are identified and incorporated into the care map. . Data cues organized data clusters which reveal Patterns of function dysfunction. OR Relationships between concepts ambiguous. Does not show critical thinking leading to the identification of the priority NDx. (5pts) Patient-centered care map developed. All components of nursing process are identified and incorporated into the care map. Data clusters which reveal Patterns of function or dysfunction. Relationships between concepts clearly indicated to include influences, results, and how each step of the nurse process affects the others. Does not show critical thinking leading to the identification of the priority NDx (8pts) Patient-centered care map developed. All components of nursing process are identified and incorporated into the care map. Data clusters reveal Patterns of function or dysfunction (labeled). Relationships between concepts clearly indicated to include influences, results, and how each step of the nursing process affects the others. Demonstrates critical thinking leading to the identification of the priority NDx. (10pts) Communicate knowledge in a manner that is concise, balanced, and logically organized; Demonstrates professional writing and communication skills to explain planning of care. De-identifies patient data and clinical setting. Does not communicate knowledge in a manner that is concise, balanced, and logically organized; does not demonstrate professional writing and communication skills; does not apply APA style and formatting for references and citations. (0 pts.) Partially communicates knowledge in a manner that is concise, balanced, and logically organized; Partially demonstrates professional writing and communication skills to explain planning of care; applies APA style and formatting; assignment contains > 20% errors. (2 pts)

Communicates knowledge in a manner that is concise, balanced, and logically organized; Demonstrates professional writing and communication skills to explain planning of care; applies APA style and formatting for references and citations with ≤ 20% errors. (4 pts)

Communicates knowledge in a manner that is concise, balanced, and logically organized; Demonstrates professional writing and communication skills to explain planning of care; applies APA style and formatting for references and citations with no errors.(5 pts)

Total Points Available (NSG 240)

100

Total Points Available (NSG 315, 350, NSG 430)

120

Satisfactory (80 points NSG 240)

Satisfactory (96 points NSG 315, 350, 430)

If satisfactory not met, correct named deficiencies and resubmit for further evaluation on ________ Initials____________

Faculty signature: ______________________ Student signature: __________________________

3.14.18 df


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