Plan of Care Assignment (21 points)
Create a care plan for the client that you assessed. You may use any format for organizing your information or you may use the charts below. This will be graded based on the attached rubric.
Write TWO actual nursing diagnosis.
Each diagnosis should include 3 parts written correctly (diagnosis, “relate to” factor, “as evidenced by” factor
Include 1 SMART goal for each diagnosis
Include 5 interventions for each diagnosis that will direct all nurses in caring for this patient.
At least one intervention needs to be related to safety. Please highlight this intervention in purple.
At least one intervention needs to be from evidence-based research. Please highlight this intervention in green.
At least one intervention needs to be about client education. Please highlight this intervention in light blue.
Include a rationale for each intervention.
Include the criteria that would be used for evaluation
Write ONE potential nursing diagnosis.
Should include 2 parts written correctly (risk for diagnosis, “related to” factor)
Include 1 SMART goal for each diagnosis
Include 5 interventions that will direct all nurses in caring for this patient.
At least one intervention needs to be related to safety. Please highlight this intervention in purple.
At least one intervention needs to be from evidence-based research. Please highlight this intervention in green.
At least one intervention needs to be about client education. Please highlight this intervention in light blude.
Include a rationale for each intervention.
Include the criteria that would be used for evaluation.
Write ONE nursing diagnosis (either actual or potential) based on a psychosocial need instead of a physical need. Use the same criteria as above for writing goals, interventions, rationales, and evaluation.
Submit to D2L dropbox by designated time.
Category and Score
3 points
2 points
1 point
0 points
Assessment
Assessment data is correct and directly related to the chosen diagnosis
Assessment data is correct most of the time and related to the chosen diagnosis most of the time
Assessment data is correct some of the time and weakly related to the chosen diagnosis
Assessment data is incorrect and not related to the chosen diagnosis
NANADA-II
Nursing Diagnosis
Diagnosis is correct in relation to client’s condition, is written in NANDA language, and is individualized
Diagnosis is correct in relation to client’s condition, is written in NANDA language but is not individualized
Diagnosis is correct in relation to client’s diagnosis, is not written in NANDA language, and is not individualized
Diagnosis is not correct in relation to client’s condition, is not written in NANDA language, and is not individualized
(NOC)
Outcomes
Outcomes are written clearly, related to the NANDA diagnosis, are individualized and attainable by the client
Outcomes are written clearly, related ot the NANDA diagnosis, are individualized, but not attainable by the client
Some outcomes are clearly written, related to the NANDA diagnosis, individualized, and some are attainable by the client
Outcomes are not clearly written, not related to the NANDA diagnosis, not individualized and not attainable by the client
(NIC)
Nursing Interventions and Rationale
Interventions are related to the NANDA diagnosis and are individualized. Interventions and rationales are based on NANDA language
All interventions are related to the NANDA diagnosis and are individualized. Some interventions and rationales are not based on NANDA language
Some interventions are related to the NANDA diagnosis and are individualized. Some interventions and rationales are not based on NANDA language
Interventions are not related to the NANDA diagnosis and not individualized. Interventions and rationales are not based on NANDA language
Evaluation
Evaluation is precise and indivates the client’s progress or lack or progress. Evaluation is individualized and shows that revisions in the plan of care as needed
Evaluation is lacking some details of precision in client’s progression and individualization of care. Evolution shows revision in the plan of care most of the time
Evaluation is lacking many details of precision in the client’s progression, and individualization of care. Evaluation shows revisions in the plan of care some of the time.
Evaluation is not precise, does not show the client’s progress or lack of progress. Evaluation is not individualized and does not show the revision in the plan of care
Spelling and Grammar
No spelling or grammar errors were made
1-2 errors in spelling or grammar were made
3-4 errors in spelling or grammar were made
5 or more errors in spelling or grammar were made
Resources
All resources used are credible and cited with proper APA format. Minimum of 3 resources were used
Most sources used are credible and most are cited with proper APA format. Three resources were used
Some sources are credible and not always cited in proper APA format. Only 2 resources were used
All resources are not credible and/or not cited with proper APA format. Only 1 resource used
Nursing Diagnosis #1
Assessment Data
Nursing Diagnosis and Client Outcome
Nursing Interventions
Safety
Evidenced-Based Research
Client Education
Rationale for interventions
Evaluation
Nursing Diagnosis #2
Assessment Data
Nursing Diagnosis and Client Outcome
Nursing Interventions
Safety
Evidenced-Based Research
Client Education
Rationale for interventions
Evaluation
Nursing Diagnosis #3
Assessment Data
Nursing Diagnosis and Client Outcome
Nursing Interventions
Safety
Evidenced-Based Research
Client Education
Rationale for interventions
Evaluation
Nursing Diagnosis #4
Assessment Data
Nursing Diagnosis and Client Outcome
Nursing Interventions
Safety
Evidenced-Based Research
Client Education
Rationale for interventions
Evaluation
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