Pathophysiology

NURS_481L – NURS 481L Concept Map Rubric

NURS_481L – NURS 481L Concept Map Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome1. Pathopysiology for admitting diagnosis, S/S, Diagnostic test and proposed treatment
10 pts

Proficient

Pathophysiology 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 pts

Acceptable

Pathophysiology 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 pts

Needs Improvement

Pathophysiology 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 pts

Unsatisfactory

Pathophysiology 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 pts
This criterion is linked to a Learning Outcome2. History of other health problems, hospitalizations, surgeries, and social issues
10 pts

Proficient

Complete 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 pts

Acceptable

Some 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 pts

Needs Improvement

Vague 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 pts

Unsatisfactory

No 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 pts
This criterion is linked to a Learning Outcome3. Family, Culture and Ethnic background
10 pts

Proficient

Complete 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 pts

Acceptable

Some 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 pts

Needs Improvement

Vague 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 pts

Unsatisfactory

No 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 pts
This criterion is linked to a Learning Outcome4. Teaching Assessment and Patient/Client Education<br>&amp; Transfer/ Discharge Planning<br>*Consider Interprofessional consults as needed
10 pts

Proficient

Complete information provided about discharge planning

7.6 pts

Acceptable

Some information provided about discharge planning.

6 pts

Needs Improvement

Vague about the information on discharge planning.

0 pts

Unsatisfactory

No information provided on discharge planning.

 

10 pts
This criterion is linked to a Learning Outcome5. Review of Systems (Detailed Head to Toe Assessment)
15 pts

Proficient

Documents 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 pts

Acceptable

Documents 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 pts

Needs Improvement

Documents 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 pts

Unsatisfactory

Documents 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 pts
This criterion is linked to a Learning Outcome6. Nursing Diagnoses: (2 Highest Priority)<br>and 1 At Risk <br>Nursing Diagnosis-<br><br> Format: <br>Nursing Diagnosis R/T medical diagnosis or condition, AEB pertinent S/S, diagnostics and supporting data
7.5 pts

Proficient

All 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 pts

Acceptable

All 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 pts

Needs Improvement

Any 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 pts

Unsatisfactory

Nursing 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 pts
This criterion is linked to a Learning Outcome7. Nursing Outcome/<br>Goal and Evaluation
7.5 pts

Proficient

The 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 pts

Acceptable

The 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 pts

Needs Improvement

The 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 pts

Unsatisfactory

The 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 pts
This criterion is linked to a Learning Outcome8. Nursing Interventions
7.5 pts

Proficient

Clearly 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 pts

Acceptable

Adequately 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 deviation

4.5 pts

Needs Improvement

Vaguely 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 diagnosis

0 pts

Unsatisfactory

Fails 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 assessment

 

7.5 pts
This criterion is linked to a Learning Outcome9. Medications
10 pts

Proficient

Lists 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 pts

Acceptable

Lists 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 pts

Needs Improvement

Lists 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 pts

Unsatisfactory

Lists 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 pts
This criterion is linked to a Learning Outcome10. Pertinent Lab Tests and Diagnostic Tests/ Procedures
7.5 pts

Proficient

Clearly 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 pts

Acceptable

Adequately identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

4.5 pts

Needs Improvement

Vaguely identifies and explains abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

0 pts

Unsatisfactory

Fails to identify and explain abnormal findings for pertinent current laboratory and diagnostics test results related to patient’s/client’s disease process.

 

7.5 pts
This criterion is linked to a Learning Outcome11. General Organization
5 pts

Proficient

Accurate APA format; Appropriate citations and references; No spelling or grammar errors.

3.8 pts

Acceptable

Adequate APA format; Minimal citations and references are appropriate; Few spelling or grammar errors.

3 pts

Needs Improvement

Numerous APA format errors; Inaccurate citations and references; Few spelling and grammar errors.

0 pts

Unsatisfactory

Fails to utilize APA format; No citations or references included; Numerous spelling and grammar errors.

 

5 pts
Total Points: 100

Concept Map (TEMPLATE)

Student Name:

Instructor:

DATE Care Provided and UNIT:

 

 

 

Patient Information

(1)

Patient Initials:

 

Age & Gender:

 

Height/Weight:

 

Code Status:

 

Living Will/ DPOA:

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? (USE SEPARATE ATTACHED WORD DOC WHEN NEEDED)

 

 

 

 

 

 

Medical History: (SEE RUBRIC REQUIREMENTS)

PAST DIAGNOSED MEDICAL PROBLEMS

 

 

 

 

 

 

 

Surgical History: (SEE RUBRIC REQUIREMENTS)

PAST DIAGNOSED SURGICAL PROBLEMS

 

 

 

 

 

Social History:

SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE

 

Chief Complaint

 

 

 

 

Admitting Diagnosis & Admission Date

 

 

 

Erickson’s Developmental Stage Related to pt. & Cite References (1) *List and Discuss specific stage (based on objective assessment)

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH)

❋Economic Stability ( MAY DELETE THESE ‘TIPS” TO USE SPACE)

❋ Education

❋Social and Community Context

❋ Health and Health Care

❋ Neighborhood and Built Environment

 

 

 

 

 

 

Concept Map (TEMPLATE)

Student Name:

Instructor:

DATE Care Provided and UNIT:

 

 

 

Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)

 

 

Lab Tests

 

Normal Ranges

Admission Lab Values

 

Current Lab Values

Explain Abnormal Labs R/T Your Pt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCLUDE: Appropriate Diagnostic Tests/ Procedures- DATEs and RESULTS

 

(Can add See attached Word Doc)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANTICIPATED TRANSFER/ DISCHARGE PLANNING:

DISCUSS: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE

 

EQUIPMENT ( MAY DELETE THESE ‘TIPS” TO USE SPACE)

 

MEDS

 

TREATMENT

 

REFERRALS NEEDED

 

Medical Management and Collaborative Plan

(from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours

 

Patient Education (In Pt.) for Transfer/ Discharge Planning

 

ASSESS LEARNING STYLE:

LEARNING PREFERENCE: WRITTEN, VIDEO, etc.

 

 

 

LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL

ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc.

 

 

 

 

 

 

 

 

Medications & Allergies (2)

 

Medication Name

Dose

Route

Freq.

Indications (PRN meds must include MD ordered Indication)

Mechanism of Action

Side Effects/

Adverse Reactions

Nursing Considerations

RN Considerations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Concept Map (TEMPLATE)

 

Student Name:

Instructor:

DATE Care Provided and UNIT:

 

 

 

Respiratory (7)

 

 

 

 

Cardiovascular (6)

 

 

 

 

Vital Signs (4)

 

 

 

 

Neurological (5)

 

 

 

 

 

 

ASSESSMENT/

REVIEW OF SYTEMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Musculoskeletal

(8)

 

 

 

 

 

 

 

 

 

 

 

GI

Hydration/Nutrition (9)

 

 

 

GU (10)

 

 

 

 

Rest/ Exercise (11)

 

 

 

 

 

 

 

 

 

 

Integumentary (12)

 

 

 

 

Misc.

 

Psychosocial (14)

 

 

 

Endocrine (13)

 

 

 

 

 

 

 

 

Concept Map (TEMPLATE)

 

Student Name:

Instructor:

DATE of Care Provided and UNIT:

 

 

 

Priority Nursing Diagnosis #1

 

 

Priority Nursing Diagnosis #2

 

 

PLAN OF CARE

 

 

 

 

 

Evaluation #1

 

 

Intervention #1

 

 

 

 

 

 

At Risk Dx.-

 

 

 

 

 

Outcome/Goal #1

 

Outcome/Goal #1

 

At Risk Interventions

 

At Risk Outcomes/

Goal

 

Evaluation #2

 

 

 

 

 

At Risk Evaluation Plan

 

 

 

 

 

Interventions # 2

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