Pathophysiology Expected Symptoms Assessment Nursing Diagnosis Medications Patient Safety
Pathophysiology Expected Symptoms Assessment Nursing Diagnosis Medications Patient Safety
| Required Elements | Points Possible | Points Received | Comments |
| Pathophysiology: Admitting diagnosis and primary diagnosis of concern. Is this diagnosis pertinent to course content? Did the student give a definition based on the textbook? | 5 | ||
| Expected Symptoms: Were actual and potential symptoms listed and pertinent to this disorder? | 5 | ||
| Assessment:
Targeted Physical Assessment: Were pertinent symptoms related to disorder identified? Were specific things listed that the student would assess for? System Assessment Findings: Was a system specific targeted to diagnosis assessment listed? General Survey: Was a general survey documented and covered all areas? (Head to Toe) |
10 | ||
| 3 Nursing Diagnosis, meaningful to this patient. Not more than one “at risk for”. Used Maslow’s Hierarchy & NANDA | 10 | ||
| Interventions: 3 for each of the three Nursing Diagnosis based on NANDA | 10 | ||
| Outcomes must be measurable. Take off points if student uses “by end of shift” NANDA | 5 | ||
| Medications: Were the medications listed, stating dose, timing, and purpose. Were nursing considerations listed? Cite drug book | 10 | ||
| Lab Tests and Treatments: Were lab values listed pertinent to patient’s diagnosis? Did student list the actual value and normal range and state why they were abnormal? Were the signs and symptoms listed appropriate to the abnormal lab value *If no labs have been drawn recently, student should say what labs should be drawn for the patients diagnosis. Cite Lab book or textbook | 5 | ||
| Resources: Did student list who should be involved in the patient care, how interdisciplinary teamwork and collaboration promoted patient care and affect the outcome of care? Did student state how this was communicated? | 5 | ||
| Interesting aspects of care: Did student identify what they felt was the most interesting aspect of this patient related to their diagnosis and care? Why they chose this patient as their case study? | 5 | ||
| Patient Safety: Did the student describe factors that create a culture of safety. How were observations or concerns related to patient safety communicated to families and the health care team? Discuss any potential and/or actual impact of National Patient Safety Goals, initiatives and regulations related to your patient and the care setting of your clinical rotation. | 5 | ||
| Teaching plan/Demonstration: Was the teaching plan specific to the patient’s diagnosis, patient-centered, and an appropriate choice to the course level student is currently in. | 5 | ||
| Verbal Report Given: Did the student give a thorough verbal report. | 5
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| Presentation & Professionalism: Did student speak clearly, obtain eye contact with the audience? | 5 | ||
| APA Formatting | 10 | ||
| Total Grade | 100 | Final Score: | |
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Case Study/Care Plan Grading Rubric 2018
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