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Learning Goal: I’m working on a nursing case study and need an explanation and a

by | Apr 27, 2022 | Nursing | 0 comments

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Learning Goal: I’m working on a nursing case study and need an explanation and answer to help me learn.I attached the patients info and an example of a case study what ever you cant fill out just make up NURS_481L – NURS 481L Concept Map RubricNURS_481L – NURS 481L Concept Map RubricCriteriaRatingsPtsThis criterion is linked to a Learning Outcome1. Pathopysiology for admitting diagnosis, S/S, Diagnostic test and proposed treatment10 ptsProficientPathophysiology is explained in complete detail with accurate and in-depth understanding of Admitting diagnosis. and presenting signs/symptoms supported by diagnostic tests and proposed treatment plan; APA references.7.6 ptsAcceptablePathophysiology is explained in some detail with some understanding of Admitting diagnosis and presenting signs/symptoms somewhat supported by diagnostic test and understanding to proposed treatment plan; with references.6 ptsNeeds ImprovementPathophysiology is explained vaguely with marginal understanding Admitting diagnosis. and presenting signs/symptoms vaguely supported by diagnostic test and vague understanding to proposed treatment plan; no references cited.0 ptsUnsatisfactoryPathophysiology details limited with poor understanding of chief complaint and presenting signs/symptoms does not support medical diagnosis, not supported by diagnostic tests and with no proposed treatment plan; no references cited.10 ptsThis criterion is linked to a Learning Outcome2. History of other health problems, hospitalizations, surgeries, and social issues10 ptsProficientComplete details given of other health problems (includes explanation of all relevant medical and surgical history) with full understanding as to its relation to the patient’s/ client’s present health problem(s).7.6 ptsAcceptableSome details given of other health problems with partial explanation of all relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).6 ptsNeeds ImprovementVague details given of other health problems with minimal explanation of relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).0 ptsUnsatisfactoryNo details given of other health problems, without explanation of relevant medical and surgical history) with full understanding as to its relation to the patient’s/client’s present health problem(s).10 ptsThis criterion is linked to a Learning Outcome3. Family, Culture and Ethnic background10 ptsProficientComplete information provided about patientclient family, provides cultural point of view in illness and wellness and connects Ethnicity to health problems/ Social Determinants of Health. (APA references) Clearly and accurately identifies client’s developmental stage with explanation based on the patient’s/ client’s developmental tasks.7.6 ptsAcceptableSome information provided about patient/client family and cultural point of view in illness and wellness, somewhat connects Ethnicity to health problems, with references/Social Determinants of Health. (APA References) Adequately identifies patient’s/client’s developmental stage with explanation based on the patient’s/client’s developmental tasks.6 ptsNeeds ImprovementVague information provided about patient/client family and cultural point of view in illness and wellness, vaguely connects Ethnicity to health problems/ limited Social Determinants of Health described, no references cited. Vaguely identifies patient’s/client’s developmental stage without explanation based on the patient’s/ client’s developmental tasks.0 ptsUnsatisfactoryNo information provided about patient/client family and cultural point of view in illness and wellness, establishes no connect to Ethnicity and the health problems. Limited to no Social Determinants of Health described, no references cited. Fails to identify patient’s/ client’s developmental stage and lacks any explanation based on the patient’s/client’s developmental tasks.10 ptsThis criterion is linked to a Learning Outcome4. Teaching Assessment and Patient/Client Education
& Transfer/ Discharge Planning
*Consider Interprofessional consults as needed10 ptsProficientComplete information provided about discharge planning7.6 ptsAcceptableSome information provided about discharge planning.6 ptsNeeds ImprovementVague about the information on discharge planning.0 ptsUnsatisfactoryNo information provided on discharge planning.10 ptsThis criterion is linked to a Learning Outcome5. Review of Systems (Detailed Head to Toe Assessment)15 ptsProficientDocuments full Head-to-Toe physical assessment – relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.11.4 ptsAcceptableDocuments Head-to-Toe physical assessment – with approx. 75% + relevant to the patient/client as performed by the student. Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings.9 ptsNeeds ImprovementDocuments full Head-to-Toe physical assessment – with approx. 50% -75% relevant to the patient/client as performed by the student. Format may be moderately disorganized with mostly appropriate terms to describe both normal and abnormal assessment findings.0 ptsUnsatisfactoryDocuments full Head-to-Toe physical assessment – with approx. > 50% relevant to the patient/client missing information – as performed by the student. Format is mostly disorganized and may be lacking appropriate terms to describe both normal and abnormal assessment findings.15 ptsThis criterion is linked to a Learning Outcome6. Nursing Diagnoses: (2 Highest Priority)
and 1 At Risk
Nursing Diagnosis-

Format:
Nursing Diagnosis R/T medical diagnosis or condition, AEB pertinent S/S, diagnostics and supporting data7.5 ptsProficientAll nursing diagnoses are accurate and prioritized per format with clear etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.5.7 ptsAcceptableAll nursing diagnoses are adequate and prioritized per format with sufficient etiology and data to support the diagnosis. Nursing Diagnoses are consistent and present a correlation from the assessment data.4.5 ptsNeeds ImprovementAny nursing diagnoses that may be vague and/or is not prioritized per format with vague etiology and unclear correlation from the data to support the diagnosis. Nursing Diagnosis are consistent and presents correlation from the assessment data.0 ptsUnsatisfactoryNursing diagnoses are low priority and/or are not prioritized per format, with vague etiology and unclear correlation from the data to supports the diagnosis. Nursing Diagnoses are not consistent and do not correlation from the assessment data.7.5 ptsThis criterion is linked to a Learning Outcome7. Nursing Outcome/
Goal and Evaluation7.5 ptsProficientThe goal clearly supports the nursing diagnosis and plan of care. The goals are specific, measurable, attainable, realistic and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions.5.7 ptsAcceptableThe goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic, and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative interventions.4.5 ptsNeeds ImprovementThe goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic, measure and timed. Evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention.0 ptsUnsatisfactoryThe goals lack support and nonspecific from gathered data, Outcome criteria are not specific, realistic, measurable, attainable, nor timed. Does not evaluates effectiveness of interventions and measures goal completion. Modifies, revises and recommends alternative intervention.7.5 ptsThis criterion is linked to a Learning Outcome8. Nursing Interventions7.5 ptsProficientClearly and accurately Identifies nursing/ collaborative interventions. Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the patient’s/client’s goals and directed at the stated health deviation.5.7 ptsAcceptableAdequately Identifies nursing/collaborative interventions with adequate teaching. Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on patient’s/client’s goal and health deviation4.5 ptsNeeds ImprovementVaguely Identifies nursing/ collaborative interventions with unclear teaching. Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the patient’s/client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis0 ptsUnsatisfactoryFails to identify nursing/ collaborative interventions and teaching. Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Interventions do not focus on patient/client goals and/or the stated health deviation based on nursing assessment7.5 ptsThis criterion is linked to a Learning Outcome9. Medications10 ptsProficientLists all MAR medications (Routine and PRN) including name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.7.6 ptsAcceptableLists all MAR medications (Routine and PRN) but does not adequately medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.6 ptsNeeds ImprovementLists most MAR medications (Routine and PRN); excepts lacks medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.0 ptsUnsatisfactoryLists most MAR medications (Routine and PRN); but fails to include medication name; ordered dose; route; MD ordered indication; mechanism of action; relevant side effects and nursing considerations relevant to the patient/client.10 ptsThis criterion is linked to a Learning Outcome10. Pertinent Lab Tests and Diagnostic Tests/ Procedures7.5 ptsProficientClearly and accurately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.5.7 ptsAcceptableAdequately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.4.5 ptsNeeds ImprovementVaguely identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.0 ptsUnsatisfactoryFails to identify and explain abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.7.5 ptsThis criterion is linked to a Learning Outcome11. General Organization5 ptsProficientAccurate APA format; Appropriate citations and references; No spelling or grammar errors.3.8 ptsAcceptableAdequate APA format; Minimal citations and references are appropriate; Few spelling or grammar errors.3 ptsNeeds ImprovementNumerous APA format errors; Inaccurate citations and references; Few spelling and grammar errors.0 ptsUnsatisfactoryFails to utilize APA format; No citations or references included; Numerous spelling and grammar errors.5 ptsTotal Points: 100

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