Attached is the worksheet that correlates with this assignment. The rubric andpatient info is listed below. please let me know if you have any questions thank you
GRADING RUBRIC FOR PATIENT CARE WORKSHEET (1)
GRADING RUBRIC FOR PATIENT CARE WORKSHEET (1)
| Criteria |
Ratings |
Pts |
|
This criterion is linked to a Learning OutcomeI. Patient InformationA. Chief complaint on admission
B. Admitting diagnosis and /or current diagnosis.
|
| 10 pts
Excellent
Thorough assessment of data. Explained in detail including an accurate and in-depth understanding of chief complaints and presenting signs/symptoms of the disease process
|
7.5 pts
Good
Data underdeveloped. Less accuracy in detail and understanding of chief complaints and presenting signs/symptoms
|
5 pts
Average
Missing data. Minimal detail and limited understanding of chief complaints and presenting signs/ symptoms
|
2.5 pts
Poor
50% of data missing. Absence of detail and understanding of chief complaints and presenting signs/symptoms of the disease process.
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeII. History of present illnessHistory of present illness along with relevant medical history, any surgeries or medical procedures, and current physical assessment
|
| 10 pts
Excellent
Explained past medical history in detail, current physical assessment, and surgical/medical procedures.
|
7.5 pts
Good
Less detailed explanation of past medical history, current physical assessment, and surgical/medical procedures.
|
5 pts
Average
Past medical history stated but with no explanation of current physical assessment, and or surgical/medical procedures.
|
2.5 pts
Poor
Past medical history not stated nor current physical assessment, and or surgical/medical procedures.
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeIII. PathophysiologyUse of Pathophysiology to explain disease and comorbidities.
|
| 10 pts
Excellent
Pathophysiology for each medical diagnosis and related comorbidity thoroughly discussed along with how it relates to the patients history and clinical manifestations.
|
7.5 pts
Good
Pathophysiology of two or more diagnosis and related comorbidities thoroughly discussed related to the patients history and clinical manifestations.
|
5 pts
Average
Lack of discussion of pathophysiology of one or more diagnosis and related comorbidities related to the patients history and clinical manifestations.
|
2.5 pts
Poor
Absence of pathophysiology of diagnosis and related comorbidities. Discussion of diagnosis not related to the patients history and clinical manifestations.
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeLab and DiagnosticsIV. Abnormal lab and hemodynamic values are explained
|
| 10 pts
Excellent
Identified ordered /prescribed laboratory and diagnostic tests. Provide detail explanation of abnormal results.
|
7.5 pts
Good
Listed the majority of ordered and or prescribed laboratory and diagnostic tests, abnormalities explained
|
5 pts
Average
Stated few ordered/ prescribed laboratory and diagnostic tests. Provides partial explanation of abnormal results.
|
2.5 pts
Poor
Ordered /prescribed laboratory and diagnostic tests are not explained. Failed to explain about abnormal results
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeV. NutritionV. Diet including NPO status, enteral feeding, or parenteral nutrition [TPN, PPN, and Intralipids]
|
| 10 pts
Excellent
Identified ordered and documented prescribed diet, identified/ prioritized risk or potential problems and teaching, nursing interventions discussed in depth
|
7.5 pts
Good
Stated ordered and /or prescribed diet; however, did not prioritize risk for or potential problems and less detail teaching and /or nursing interventions are discussed
|
5 pts
Average
Stated ordered and or prescribed diet Did not identify or prioritize risk for or potential problems. Provided minimal teaching, and included few nursing interventions.
|
2.5 pts
No Marks
Did not document ordered and or prescribed diet, failed to identify or prioritize risk or potential problems. Provided no teaching, stated few nursing interventions
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeVI. Physical AssessmenVI. Physical Assessment (respiratory care modalities)
|
| 10 pts
Excellent
Listed all body systems and identified the abnormalities that are relevant to patients diagnosis and nursing problem/diagnosis
|
7.5 pts
Good
Listed most of the body systems and identified most abnormalities relevant to patients diagnosis and nursing problem/diagnosis
|
5 pts
Average
Listed 50% body systems and identified most abnormalities relevant to patients diagnosis and nursing problem/diagnosis
|
2.5 pts
No Marks
Listed few body systems and identified most abnormalities relevant to patients diagnosis and nursing problem/diagnosis
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeVII. Medications
|
| 10 pts
Excellent
Listed all current medications citing rationale and relevance to patients diagnosis and nursing problem/diagnosis
|
7.5 pts
Good
Listed most of the medications on MAR and relevance to patients diagnosis and nursing problem/diagnosis
|
5 pts
Average
Listed 50% of the medications on MAR and relevance to patients diagnosis and nursing problems/diagnosis
|
2.5 pts
Poor
Listed no medication related to patients medical condition
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeVIII. Expected collaborative interventionsVIII. Expected collaborative interventions (Evidence-based practice: EBP)
|
| 10 pts
Excellent
Discussed detailed nursing intervention, recommended treatments, and teaching based on EBP
|
7.5 pts
Good
Discussed less detailed nursing intervention, recommended treatments, and teaching. Minimally utilized EBP
|
5 pts
Average
Lack of discussion on nursing intervention, recommended treatments, and teaching. Not based on EBP
|
2.5 pts
Poor
Failed to provide recommended treatment with teaching, with no nursing interventions discussed. Not based on EBP
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeIX. References
|
| 10 pts
Excellent
3 sources from multiple peer-review articles/journals in last 5 years
|
7.5 pts
Good
2 sources from multiple peer-review articles/journals in last 5 years
|
5 pts
Average
1 source from peer review articles/journals in 10 years
|
2.5 pts
Poor
Failed to provide reference from single peer review article/journal
|
|
10 pts
|
|
This criterion is linked to a Learning OutcomeX. Overall quality of the paper- Coherent, Grammar, punctuation.
|
| 10 pts
Excellent
No errors
|
7.5 pts
Good
Few errors (<than 3)
|
5 pts
Average
Some errors (<than 5)
|
2.5 pts
Poor
Many errors
|
|
10 pts
|
|
Total Points: 100
|
Patient: MW
Age: 91 yo
Sex:Female
Vital Signs:
126/68
Temperature: 98.1
Heart rate: 76
Respiratory rate: 16
O2 saturation: 99%
Weight: 145 lbs
Diagnosis: Lobar Pneumonia, unspecified organism
History: Atherosclerosis of aorta
DM2
Chronic Dysphagia
Chronic kidney disease
Contracture of muscle multiple sites
Hypoosmolarity
Hyponatremia
AKF, Disorder of kidney
Acute angle closure glaucoma bilateral
Anemia in CKD
Generalized OA
Cataracts
Orders:
OT skilled services, QDS x wk 30 days
Cleanse GT
May crush meds
Enteral feed
May have foot cradle to prevent skin breakdown
Podiatry
Dental
Opthamology consult
Labs:
WBC:8.77
RBC: 3.21
HGB:10.0
HCT:31.7
MCV:98.8
MCH: 31.2
MCHE: 31.5
RDW:13.3
Platelets:253
Lymphocytes: 14.4%
Monocytes 5.4%
Neutrophils: 77.5%
TSH:0.46
T4 free: 0.60
T3 free:2.3
Sodium: 135
Potassium: 5.6
Glucose: 259
BUN:12
Creatinine:0.8
CA:8.7
Medications:
Apixaban oral tablet 2.5 mg 1x daily
Famotdine oral tablet 20 mg 1x daily
Amiodarone HCI oral tablet 200mg 2x day
Prostat 30ml day via g-tube 1x daily
Memantine HCI oral tablet 5mg 2x day
Metformin HCI oral tablet 1000 mg 2x day
Skin:
Intact, no redness, no skin breakdown.
