RNSG 2361
Clinical
Module Assignment:
Care Plan
Student LerShoniter Brown
: :
Grading Rubric
3 <3-2
Appropriate medical terms and/or
abbreviations used throughout
Highest Priority (according to
student) NANDA fully developed
Source is documented correctly using
APA format
13
Minimum of 3 appropriate NANDA
problems identified, properly written,
and properly prioritized
Subjective & objective data included
that are defining characteristics of
nursing diagnosis
Well written Goals which include:
Appropriate short term and long term
goals; outcomes that are: specific,
realistic & measurable, a definite time
frame for achievement, and
consideration of patient’s desires &
resources
2010 Lamar State College – Port Arthur
Date: 4/24/2011
1 - 2 inappropriate medical term
and/or abbreviation used
Highest Priority (according to
student) NANDA development
incomplete
<13-6
1-2 errors in: Minimum of 3
appropriate NANDA problems
identified, properly written, and
properly prioritized
Either subjective or objective data is
missing on care plan or data is not a
defining characteristic of developed
nursing diagnosis
Goals include all but one of criteria:
appropriate short term and long term
goals; specific, realistic & measurable,
a definite time frame for
achievement, and consideration of
patient’s desires & resources
Instructor Shirley MacNeill
<2-0 Points Earned
>2 Inappropriate medical term
and/or abbreviation used
Developed NANDA not the highest
priority without preapproval
Source is not indicated or APA format
is incorrectly used
<6-0 Points Earned
>2 errors in: Minimum of 3
appropriate NANDA problems
identified, properly written, and
properly prioritized
Subjective or objective data is
missing on care plan and data is not a
defining characteristic of developed
nursing diagnosis
Goals missing >1 of criteria:
appropriate short term and long term
goals; specific, realistic & measurable,
a definite time frame for
achievement, and consideration of
patient’s desires & resources
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RNSG 2361
Clinical
Interventions: relate to the goals;
are specific and clearly stated to
include: Who performs, how,
when, where, time/frequency, &
amount
Interventions are correctly identified
as (I) Independent or (C)
collaborative
Rationale indentified for each
intervention and includes source and
correct page number
Appropriate evaluations are included
for short term and long term goals
Late Penalty:
25 points up to 24 hours
Greater than 24 hours will result in a
zero for the assignment
2010 Lamar State College – Port Arthur
Interventions include all but one of
criteria: relate to the goals; are
specific and clearly stated to include:
Who performs, how, when,
where, time/frequency, &
amount
1 - 2 interventions are not identified
as (I) Independent or (C)
collaborative or one intervention is
incorrectly labeled
1 - 2 rationales are not indentified for
each intervention or incorrect source
and page number given
Inappropriate or incomplete
evaluations for 1-2 short term or
long term goals is present
Comments:
Interventions missing >1 of criteria:
relate to the goals; are specific and
clearly stated to include: Who
performs, how, when, where,
time/frequency, & amount
>2 interventions are not identified as
(I) Independent or (C) collaborative
or >1 interventions is incorrectly
labeled
>2 rationales are not indentified for
each intervention or incorrect source
and page number given
Inappropriate or incomplete
evaluations for >2 short term or
long term goals is present
Total Points Earned (maximum of
100)
Spelling and Grammar Errors
Deduction (maximum of 10
points)
Late Points Deduction
Failure to submit electronically
as an attachment in proper
format (MS Office Word) with
grading rubric as first page of
document
Points deduction (maximum of
10 points)
Final Score
Page 2
RNSG 2361
Clinical

Problem List

List and prioritize a minimum of 3 problems.

Type your answers in the space provided. The boxes will expand as you type.

Problem # Date Nursing Diagnosis R/T Etiology AEB Subjective/Objective Data

1. 4/24/2011 Powerlessness R/T interpersonal interaction and helplessness AEB

dependence on others, anger, frustration and dissatisfaction in not being
able to participate in decision making and control over her discharge from
the hospital

2. 4/24/2011 Ineffective coping r/t inadequate level of perception of control AEB

inability to meet basic and inability to meet role expectations.

3 4/24/2011 Chronic low self-esteem R/T repeated unmet expectations AEB depending
on others, frequent lack of success with wound healing.

           

           

           

           

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RNSG 2361
Clinical

Diagnosis by Nanda
Type your answers in the space provided. The boxes will expand as you type.

DIAGNOSIS BY PLAN/GOAL INTERVENTION RATIONALE EVALUATION

NANDA (Indicate I or C) (Page #)

NANDA #1: SHORT TERM: Patient will:

Powerlessness R/T
interpersonal 1. Patient will 1. The nurse and wound 1. Older adults who 1. Short term goal #1
interaction and state feelings of care team will explore the engage in control of met 100% (Mon at
helplessness AEB powerless and patient’s feelings of their health problems 1000). AEB Patient
dependence on other feelings powerless. ( C) had fewer depressive verbalize that she
others, anger, related to symptoms. (page wasn’t giving up and
frustration and powerless with 668) she’s going to do
dissatisfaction in not the first eight what it takes to heal.
being able to hours of a
participate in twelve hour
decision making and shift.
control over her
discharge from the
hospital

AEB 2. Patient will 2. The nurse will establish a 2. For hospitalized 2. Short term goal #2
ask question therapeutic relationship by patients it was found met 100% (Mon at
Subjective Data: about care and listening and allowing the that lack of staff 1100). AEB Patient
treatment within support in the form was able to ask all

2010 Lamar State College – Port Arthur Page 4

RNSG 2361
Clinical

Patient states, “I the shift at 1900 patient time to question. (I) on listening to the question concerning
can’t eat what I want patient. (Page 667) wound related
and I have a wound problems and
on my left foot that healing.
has been there for
over a year”. 3. Patient will 3. The nurse and wound 3. An external locus 3. Short term goal
Patient also states, participate in care team will assess the of control can #3 met 100% (Mon
“If this wound don’t the care and patient locus of control to negatively influences at 1800). AEB
heal they going to treatment within her health. (C) patient’s perception Patient identified
cut my foot off”. the shift at of power over their areas in which she
1900. health. (page 666) can assume more
difficulty falling responsibility of her
asleep health by.

Objective Data: 4. Patient will 4. The nurse will encourage 4. Patients are more 4. Short term goal
Identify factors the client to take control of amendable to therapy #4 met 100% (Mon
that are as many ADL’s as possible. if they know what to at 1400). AEB client
Sad mood, sleeps controllable expect. (page 667) allowed to assist in
(I)
only four hour at during an eight wound care dressing
night, decrease social hour shift. change and sit in
interaction wheelchair and
complete upper body
Changes of skin
ADL’s
color at pressure site,
destruction of skin
LONG TERM: Patient will:
layer,
pain, change in tone 1. Patient and family will be referred to additional resources for psychological therapy,
as patient speaks
diabetic and wounds care, nutritionist and physical therapy and for lifestyle changes and
about foot
recommendations to enhance quality of life.
restlessness, Posture
bent/slouched

Sources (APA Format):

Ackley, B. J., & Ladwig, G. B. (2008). Nursing Diagnosis Handbook: A guide to planning care (8th

Ed.). St. Louis, MO: Mosby Elsevier

Ignatavicious, D. D. & Workman, M. L. (2010). Medical-Surgical Nursing and Virtual Clinical

Excursions 3.0 Package, (6th Ed). St. Louis, MO: Elsevier Saunders.

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Clinical

Reviewed & Revised 6/14/2010

2010 Lamar State College – Port Arthur Page 6