Nursing Care Plan Grading Rubric

Admitting/current medical diagnosis & definition: Student Name:

____/2 Medical diagnosis listed Date(s):

____/2 Diagnosis definition
Instructor:

Assessment Diagnosis Plan Implementation Evaluation

____/2 Objective data ____/1 NANDA approved ____/2 Goals derived from ____/3 Individualized/ ____/2 Evaluated goal
supports diagnosis diagnostic label nursing diagnosis realistic/safe for this achievement based on
____/1 Relevant nursing ____/2 Stated in patient patient outcome of AEB criteria
____/2 Subjective data diagnosis for patient behaviors ____/3 Help patient stated in goal
supports diagnosis medical diagnosis ____/2 Designed to lessen achieve stated goal ____/2 Outcome reflects
____/1 Related to (r/t) or remedy problem ____/3 Congruent with time limit set in goal
____/1 Etiology ____/2 Realistic for patient medical diagnosis ____/2 Reassessment
____/1 As evidenced by to achieve treatment orders stated goal not met
(AEB) ____/2 Identifies patient ____/3 States rationale for
____/1 Defining outcome criteria which are each intervention
characteristic observable and measurable ____/3 Rationale of
(AEBs) interventions supports goal
____/2 Sets a time limit
____/3 Citation in APA format Total: _____/50 points

Assessment Diagnosis Plan Implementation Evaluation

Include only the
Outcomes & evaluative Evaluate outcomes
supporting data Include functional Prescribed interventions, rationales & references:
criteria: & evaluative
cluster related to each health patterns Nurse will:
Patient will: criteria
diagnosis
Subjective data: “Diagnostic label” 1. Patient will (long 1a. Nurse will (ongoing assessment) rationale and reference 1. Outcome (met,
related to (r/t) term goal) 1b. Nurse will (therapeutic intervention) rationale and partially met, not
“etiology” (cause) as reference met) how and/or
Objective data: evidenced by “defining 2. Patient will (short 1c. Nurse will (education/continuity of care) rationale and why
characteristic” term goal) reference
(symptom) 2a. Nurse will (ongoing assessment) rationale and reference 2. Outcome (met,
2b. Nurse will (therapeutic intervention) rationale and partially met, not
reference met) how and/or
2c. Nurse will (education/continuity of care) rationale and why
reference
 Nursing Care Plan
Admitting/current medical diagnosis & definition: Student Name: Zyiv Balogal

Compartment Syndrome Date(s): 04/09/20

An increase in pressure inside the muscle compartments, can result in muscle and nerve damage
that may require amputation if left untreated for extended periods of time. Instructor: Mr. Norman Elizaga

Assessment Diagnosis Plan Implementation Evaluation

Include only the supporting
Include functional health Outcomes & evaluative criteria: Prescribed interventions, rationales & references: Evaluate outcomes &
data cluster related to each
patterns Patient will: Nurse will: evaluative criteria
diagnosis
Decreased Cardiac 1. Patient will maintain 1a. (Physiological Basic) Nurse will reposition patient 1. Outcome can not
Subjective data: Output related to the wellness of health every 2 hrs. and assist the pt. with ambulation as needed. be assessed at this
Pain: 7/10 altered HR, rhythm that he has been doing time because no
and afterload aeb until now and adding The patient has an increased risk of decreased cardiac further information
daily exercise for the output because of his impaired mobility allowing for has been given in
tachycardia and
next 90 days. possible clots to form due to prolonged pressure relation to the
altered BP. especially on bony prominences of the body. The cast that patient’s response to
was applied to the arm of the patient is also a the interventions
contributing factor to the decreased cardiac output so it is implemented.
important to move around the patient’s arm and ensure Expected outcome
that circulation is optimal in that region of the body. however is that the
patient has been fully
1b. (Physiological Complex) Nurse will re-assess the compliant in his
patient’s vital signs every 15 minutes and neurovascular medication regimen
checks every 30 minutes in order to monitor for any and added daily
Objective data: changes and set a trend to see if patient’s status is exercise to his
HR; 100 stabilizing, improving, or degrading. maintenance of
BP: 130/76 overall health.
CO2: 22 2. Patient will regain Reassessment of the patient’s vital signs and
RBC: 6 adequate cardiac output neurovascular condition gives us data that we can then
WBC: 10
aeb patient’s VS use to determine where the patient’s condition is headed
Hgb: 13
Hct: 38
returning to baseline towards if it will be getting worse or better. One thing to
PT: 12 values in 24-48 hrs. note in the patient is that his HR is at 100 bpm yet his BP
INR: 1.0 is only at 130/76 yet he has a history of chronic
PTT: 30 hypertension which is should be taken as an alarm that
something is not functioning properly within the patient’s
body.

1c. (Behavioral) Nurse will encourage the patient to keep

up with the maintenance of his chronic hypertension with
the use of his prescribed medications, and to add daily
exercise to his regimen as tolerated but not to the point of 2. Outcome can not
overexertion. be assessed at this
time because no
The patient has been doing good in maintaining his further information
hypertension as he has not had any complications which has been given in
means he is good at taking his medications. It is important relation to the
to encourage and remind him to continue doing it as he patient’s response to
might see this event as a reason to stop complying the interventions
because he still ended up in his situation even while being implemented.
persistent in his attempt to maintain his overall health. Expected outcome
Adding exercise as tolerable can further his goal of however is that the
maintaining his health as it can improve his respiratory patient’s vital signs
function which affects the workload of the heart and his are now within his
peripheral circulation. baseline values aeb
his HR becoming
1d. (Safety) Nurse will educate the patient of the >100 indicating that
importance of early ambulation and the warning signs of his heart’s workload
possible compartment syndrome (sensation of pressure in has been relieved and
the injured arm) and advocate for the patient and request that the body does
for his cast to be re-sized in the case that it is partly not require
responsible for the decreased cardiac output. compensation for a
decreased
By educating the patient of early ambulation he will oxygenated blood
become more encouraged to give his best in early supply. Also the
ambulation in order to prevent the post-op complication patient’s BP of
that is compartment syndrome. Also by telling him of the 130/76 will increase
early warning signs related to the condition, we are keeping in mind of
giving the patient the ability to call for help not when it his medical history of
has already occurred or in the middle of the process, but chronic hypertension,
before it starts to begin that way we can take measures the BP that the
that will try and avoid it from happening. Some cases of patient came in with
compartment syndrome can be attributed to the cast was alarming for
applied to the patient being too tight, causing pressure someone of his age
over a bony prominence and decreasing the body’s ability and medical history
to deliver oxygenated blood due to a narrowing of the indicating an
arterial walls caused by the external pressure exerted by impairment or
the cast. dysfunction in the
circulatory system.
 Nursing care plan p. 2
Student: Zyiv Balogal Date: 04/09/20 Instructor: Mr. Norman Elizaga

Assessment Diagnosis Plan Implementation Evaluation

Include only the supporting
Include functional health Outcomes & evaluative criteria: Prescribed interventions, rationales & references: Evaluate outcomes &
data cluster related to each
patterns Patient will: Nurse will: evaluative criteria
diagnosis
Subjective data: Risk for infection 1. Patient will remain 2a. (Physiological Basic) Nurse will wash hands and 1. Outcome can not
Pain: 7/10 manifested by infection free for the instruct other caregivers who can come into contact with be assessed at this
inadequate primary next 90 days or until the patient to do the same. time because no
defenses: altered skin the they have fully further information
recovered and healed Proper hand hygiene is a simple yet essential task in has been given in
integrity, stasis of
from the surgical caring for any patient. It is especially vital to the patient relation to the
body fluids, chronic procedure and break in in this scenario as he is later in age which means there is patient’s response to
disease (chronic his skin. a decrease in his body’s ability to adapt to illness and the interventions
hypertension) and the other alterations to his health. He also recently had an implemented.
recent invasive invasive surgical procedure in order to debride the Expected outcome
procedure the pt. has affected area due to bone fragments dislodging and going however is that by
just come out to the lower arm. proper hand hygiene,
monitoring the
2b. (Physiologic Complex) Nurse will monitor the patient constantly,
Objective data: patient’s WBC count as it is an early indicator of infection and with the proper
HR: 100 as well as observing the patient for any manifestations of education it can all
BP: 130/76 infection; heat, pain, swelling, redness, and loss of add up to the patient
CO2: 22 function. being infection free
RBC: 6 for the next 90 days
WBC: 10
In order to protect the patient from further post-op or until the break in
Hgb: 13
Hct: 38
complications the patient must constantly be monitored his skin preventing a
PT: 12 2. Patient will present for signs of infection such as elevated WBC count. Early serious post-op
INR: 1.0 stable VS that do not detection of infection will assist us in keeping the patient complication from
PTT: 30 indicate a possible alive and safe as if left alone it can become systemic once occurring.
infection within the 1-2 it reaches a specific part in the circulation system of the
weeks. body If it is not caught early, it is still important to catch
it, and that is why it is important to note any possible site 2. Outcome can not
of infection that is red, swollen, giving off heat, presence be assessed at this
of pain in the general area, and finally the loss or change time because no
of function. further information
2c. (Behavioral) Nurse will educate the patient to limit has been given in
social interactions for the time being, as well as avoiding relation to the
possible sources of infection such as gardening. patient’s response to
the interventions
While the break in his skin is not healed and closed it is implemented.
important that the patient try their best to avoid becoming Expected outcome is
infected with any possible infection. This is because that during the next
contracting an infection at this point in the recovery week or two the
process can set him back in his recovery process by a lot. constant observation
Another possibility that an infection will bring along with and monitoring as
it is activity intolerance further complicating the first well as the education
priority in this patient’s care. that has been
provided to the
2d. (Safety) Nurse will educate the patient on the patient will give us
importance of healthy nutritional intake as well as full and the patient the
compliance regarding the prescribed medication regimen ability to catch an
and not to stop using the medication just because his infection early on
symptoms stop. before it can make
itself a systemic
The elder population have an increased need for proper problem. it is
diet and nutrition to compensate for the decline in their important to prevent
body’s functional capability. It is important to stress to an infection in this
the patient that the recommendation for someone in his stage of the recovery
situation is a high calorie high protein diet which will process because if it
effectively help him during this recovery phase, low fat in is allowed to become
his diet is already advised due to his chronic hypertension systemic the patient
and is still important to remind him. Compliance with the may not make a full
prescribed medication regimen is vital especially in recovery or worse,
regards to the antibiotic prescribed because if he stops become septic.
using it there is a chance for a secondary infection to
occur or worse, not finishing the antibiotic can cause a
superinfection/resistant-strain of the pathogen. This can
occur if the pathogen is not completely cleared from the
body, the remaining pathogens can mutate and become
unaffected by the medications that were previously
prescribed to this patient. The elderly are ill-equipped to
handle and adapt to this situation as it can cause a
decline in their health faster than expected.
Citation: Nursing Care Plan p. 3