Student Nurse: Precious White Cedar Crest College Client Initials: L.T.

Clinical Date: 10/26/16 Course: ____309_____ Room # 21

Clinical Site: LVHN Cedar Crest 7K Clinical Preparation

Demographics 45 y.o. Female Reason for Hospitalization

S Date of Admission: 10/23/16 Allergies: NKA Chief Complaint: Right elbow pain.

Code Status: Full Code HPI: Pt. on her way to dinner in a rush, leaving the house and
fell down 4 steps onto her right elbow.
Admitting Physician: Sexton, S.
Admitting Diagnosis: Olecranon fracture, Right
Consulting Physicians: N/A
Define Medical Diagnosis: Fracture of the bony point on
Other Disciplines/Therapies involved in Client care: Urology, Case elbow. The olecranon is the proximal extremity of the ulna
management, PT which is articulated with the humerus bone and constitutes a
part of the elbow articulation.

Date & Type of Surgery/Procedure: 10/23/16 ORIF-An open

reduction internal fixation that is a surgical procedure to fix a
severe bone fracture.

PMH/PSH /Chronic Conditions (use other side if Significant abnormal Trending of Lab Inference of Abnormal Values
B needed) Labs Values
PMH/PSH/CC: Anxiety, Depression, Migraines,
Hyperlipidemia, Difficulty falling/staying asleep BUN- 5mg/dL (Low) Increasing Indicates how well kidneys are working. May
(insomnia) AST- 48U/L (High) Decreasing be low due to patient not being able to void
ALT- 56U/L (Hight) Decreasing since the surgery.
Both are blood liver tests that may indicate liver
damage/injury. May be elevated also due to
patient not being able to void since surgery and
Definitions: A mental health disorder characterized
by feelings of worry, anxiety, or fear that are Foley catheter was d/c.
strong enough to interfere with one's daily
activities; Depression is a mood disorder that
causes a persistent feeling of sadness and loss of
interest; A headache of varying intensity, often
accompanied by nausea and sensitivity to light
and sound; A condition in which there are high
levels of fat particles (lipids) in the blood.

Diagnostic Procedures (ex. X-ray, Ultra Sound, CT Scan, EKG) Results Procedure Prep or Post Care
B 1. Elbow 2 views Right- good alignment- Post op
2. Humerus Right- partially visualized right olecranon fracture- Pre-op
3. Elbow 3+ views Right- posteriorly displaced olecranon fracture- Pre-op
4. ECG- Nonspecific T wave abnormality- Post op

Medication Dose/Route/Time Drug Classification Reason client Taking Major Side Effects Associated Labs
B Bactrim D 160mg tablet/
oral/ Q12H
Antibiotic/ Anti-
infective
Suspect a UTI Fatigue, insomnia,
Hepatic necrosis,
CBC, serum
Potassium, BUN
Clostridium Difficile-
Associated Diarrhea
Heparin 5,000 u/mL/ IV/ Anticoagulant, To prevent blood clot Bleeding, aPTT, PT
Q12H Antithrombotic after surgery. thrombocytopenia,
anemia
Senokot 1 tablet/ PO/ 2x Stimulant laxative, Increase peristalsis Cramping, diarrhea CBC, BUN,
daily Stool softener after surgery for bowel Creatinine, all
movement. Electrolytes
Multivitamin 1 tablet/ PO/ Vitamins Optimal surgery Vomiting, diarrhea, Iron levels,
daily recovery constipation, loss of hemoglobin,
appetite
 hematocrit, plasma
folic acid
Ferrous Sulfate 1 tablet/ PO/ 2x Antianemics, iron Prevention/treatment Hypotension, nausea, Hemoglobin,
daily before supplement of iron-deficiency constipation, dark Hematocrit,
meals anemia. stools, epigastric pain, reticulocyte
skin staining
Oxycodone 5mg 1 tablet/ PO/ Opioid analgesics Pain Confusion, sedation, Plasma amylase
PRN Q4H respiratory depression, and lipase levels
constipation
Acetaminophen 1 tablet 325- Antipyretics, Pain Hepatic failure, Renal Serum bilirubin,
600mg/ PO/ PRN nonopioid failure, rash AST, ALT, LDH,
Q6H- dose analgesics PTT
dependent on the
total amt. of
acetaminophen in
conjunction with
oxycodone; not to
exceed
4,000mg/day
List medication patient takes at home: N/A

Vital Signs Day of Prep Day of Care Vital Signs Day of Prep Day of Care
A Temp 99.4 99.7 BP 103/59 142/80
9/10
HR 68 100 Pain 9/10
RR 18 22 O2/Pulse OX 97% O2 Room Air 97% O2 Room Air

Indicate Rationale
A IV sol, rate, site
Diet
N/A
Regular
No longer had an IV on day of care
Able to tolerate solids without restrictions
Tube Feeding N/A Able to consume solid food
Activity Order Per tolerance/ Encouraged Don’t want to push the pt. too much but also need to get them mobile after a surgery
PT Scheduled sessions To assist with ambulation and mobility after surgery
TEDS/SCD N/A Mobile enough to not need TEDS/SCDs
Finger Stick Blood Sugars N/A Not a diabetic nor have a fluctuation in glucose levels

ASSESSMENT Day of Prep Day of Care ASSESSMENT Day of Prep Day of Care
A NEUMAN SYSTEMS VARIABLES Activity/Gait

Cooperative but agitated and Equipment/ CPM/Traction Assist x1 Assist x1

1. PSYCHOLOGICAL
anxious Walker/cane/crutches N/A N/A
Pulmonary
2. DEVELOPMENTAL
Generativity vs. stagnation O2 amt/delivery mode N/A Room Air N/A Room Air
Access to healthcare with adequate O2 saturation 97% 97%
3. SOCIOCULTURAL family support; middle class, white Regular, non- Regular, non-
male, married Respiratory effort labored labored
Clear in all lung Clear in all lung
4. SPIRITUAL Lung sounds fields fields
N/A Cough/Secretions N/A N/A
5. PHYSIOLOGICAL Chest Tubes N/A N/A
CARDIO GI
Heart Sounds: rate & rhythm Regular Regular Abdomen
Normoactive in Normoactive in
all quadrants, all quadrants,
All pulses +2- All pulses +2- nontender, nontender,
Pulses: peripheral & apical Regular Regular Bowel sounds, tenderness, Distention? round and soft round and soft
Edema N/A N/A Appetite/% eaten 0% 55%
Capillary Refill <3 seconds <3 seconds Nausea/vomiting None None
Jugular Vein Distention N/A N/A Tube feeding: type/site N/A N/A
Skin Other tubes/drains N/A N/A
 Color/Temp Pink/Warm Pink/Warm GU
No tenting of No tenting of
Turgor/Moisture skin/Dry skin/Dry Urine description N/A N/A
Pink and Pink and moist
Mucous Membranes moist Catheter Foley Catheter N/A
Patent, non-
IV site tender N/A Bladder scan N/A N/A
Braden score/stage 16 16 INTAKE
NEURO Type Amt
Awake and Awake and Alert
LOC Alert IV and oral 2100 mL
Orientation X4 X4 OUTPUT
Follows commands Yes Yes Type Amt N/A
Pupils are Pupils are equal,
equal, round round and
and reactive to reactive to light
light and and
accommodate accommodate Last BM: 10/22/16
PERRLA bilaterally bilaterally Description & frequency of stools Brown, soft and formed
W/o W/o difficulty/
difficulty/ Clear
Swallow/Speech Clear Safety Issues
Musc-Skeletal Restraints N/A N/A
Bed rails up, Bed rails up,
Fall Risk Fall Risk
Extremity Strength Weak on RUE Weak on RUE Fall precautions bracelet Bracelet
Moves slowly/
Sensation Moves Slowly/
Movement/ Sensation intact Sensation intact HOH N/A N/A
Passive and Passive and
limited ROM limited ROM on Can easily read Can easily read
ROM on RUE RUE Vision newspaper print newspaper print
Other Fall Score 13 13

Dressings & Wound Care Plan of Care (Your Concept Map)

R N/A ATTACHED

Other Treatments (ex. Chest tubes, feeding tubes) Teaching Goals

N/A Coping methods to reduce anxiety/ depression, pain medication limits,

nutrition

Discharge Plan:
N/A
 Cedar Crest College
Physiological Stressor # 1 Physiological Stressor # 2 P
Student Concept Map, p1
R
S “I’m just not hungry.” “I don’t feel like S “This feels like torture.” E
eating.” Life threatening stressors
C
penetrate Core O pain 9/10 right elbow, grimacing face, I
O 0% food eaten, pain 9/10 right elbow, not Abnormal Symptoms penetrate gripping bed rail, taking oxycodone Q4H, O
in the mood to order food, lethargic, agitated. HR 100, RR 22, BP 142/80, x-ray positive of U
normal line of defense
right olecranon fracture. S
A Imbalanced Nutrition: less than body Stressors penetrate flexible line of
W
requirements R/T insufficient dietary intake defense & ^risk for penetration of NLD A Acute pain R/T surgery of elbow AEB H
AEB 0% food eaten, lethargic & agitated. pain 9/10, grimacing face, gripping bed rail I
& using oxycodone Q4H. T
P Patient will consume adequate E
nourishment. P Patient will state relief of pain.
11
Medical Diagnosis: 21
Right Olecranon 16
Fracture
Cc: Right elbow pain

Positive Variable
Positive Variable CC: Aiding Resistance
Ct. Stage of
Aiding Defense
dev.
Generativity Patient receiving
Patient’s husband vs. adequate ROM for
comes every day after Stagnation corrected right
work to visit. olecranon fracture.

HPI: Fell down 4 steps, landing onto

point of elbow.

Other Stressor # 4
Physiological Stressor # 3

S “How am I supposed to do anything

S “I feel like I have to go, but I just can’t.” with this cast?”

Flexible line of defense

O D/C Foley catheter, no urinary output since O Full right arm cast, assist x1, fall score
surgery, low BUN of 5, distended bladder, 13, lethargic, urge to void.
sensation of full bladder, anxiety regarding the Normal line of defense
situation and circumstances. A Risk for Falls R/T postoperative
Lines of Resistance conditions.
A Urinary Retention R/T the disruption of
nerve impulses between the brain and bladder P Patient will remain free of falls.
AEB sensation of full bladder but not being able Basic Structure/Central
to void & no output since surgery. Core

P Patient will void after the urge to do so.


Student Name: Precious White
Nursing Dx #1: Imbalanced Nutrition: less than body requirements R/T insufficient dietary intake AEB 0% food eaten, lethargic & agitated.
Behavioral Outcome: The patient will finish at least 50% of lunch on the day of care.
Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/ goals)
Offer frequent, small meals.
(Independent)
Keep the patient’s environment
neat and clean.
(Independent)
Use a nutritional screening tool to
recognize nutritional
requirements and if necessary
refer to dietician.
(Collaborative)
Observe for potential barriers to
eating such as willingness, ability
and appetite.
(Independent)
Cedar Crest College - Nursing Concept Map (page 2)
Attach Clinical prep sheet to this form
Scientific Rationale for Selected
Interventions
“This helps prevent gastric
distention and improves appetite by
keeping the patient from being
overwhelmed with a large amount of
food” (Treas & Wilkinson, 2014, p.
934).
“Unpleasant sights, odors, and
medical equipment can often trigger
loss of appetite” (Treas & Wilkinson,
2014, p. 934).
“This tool can assess weight, dietary
intake and muscle wasting, allowing
for early identification and
prevention of nutritional decline”
(Ladwig et al., 2014, p. 537).
There are many factors contributing
to a patient’s appetite. Assessing
further will allow for a better
understanding of the overall picture
(Treas & Wilkinson, 2014. p.934).
Client Initials: L.T.
Implementation Phase (Indicate
what you, the nurse, the
therapist, etc did on the day of
care)
Encouraged patient to take two
bites of toast and eat one small
bite of eggs at 0930.
Encouraged patient to finish all
of toast, half of the applesauce
and one bite of grilled chicken at
1130.
Cleared the patient’s table of bed
pan, emesis basin and papers.
Asked the patient and primary
nurse questions regarding
patient’s overall health and
nutrition over the past few
months like: weight, eating
habits, current mobility, stress
and any other illnesses.
Implemented therapeutic
communication and listened to
the patient talk about her
surgery and feelings, especially
of anxiousness after the surgery.
Evaluation Phase (Note specific
and measurable data you collected
after the intervention to give
evidence if your planned
interventions helped the client)
Patient able to consume and
tolerate the two bites of toast and
one small bite of eggs for
breakfast.
Patient able to consume and
tolerate all of toast, half of
applesauce and one bite of
chicken; finishing at least 50% of
lunch.
Patient able to have more room on
the table and a neater
environment to eat in.
Patient able to provide answers
regarding her health over the past
few months, stating: a maintained
weight, controlled and balanced
eating habits, active and out of the
bed for majority of the day,
normal amount of stress from
work and free of any other
illnesses. Patient stated “None of
this has to do with why I don’t
have an appetite, though.”
After listening, could depict the
main barrier of eating was anxiety,
producing not much of an
appetite.
 Control pain often enough.
(Collaborative)
Outcomes met? Why or Why not? Explain: Patient ate at least 50% of lunch with some encouragement, therapeutic communication and pain
maintenance. Outcome fully met.
“Avoiding painful treatment before
meals allows for a patient to be
more willing to participate” (Treas &
Wilkinson, 2014, p. 934).
Watched the primary nurse give The pain medication somewhat
oxycodone Q4H PRN. alleviated patient’s pain. It went
from a 9 /10 to a 6/10, which in
Watched Physical therapy turned made for a more willing
attempt to get patient OOB after patient to try and eat and relax.
breakfast and after lunch.
Pain medication was coordinated
with therapy; which both were
done after meals. Patient able to
get up OOB and tolerated being
mobile for a few minutes.

Cedar Crest College - Nursing Concept Map (page 3)

Attach Clinical prep sheet to this form
Student Name: Precious White Client Initials: L.T.
Nursing Dx #2: Acute pain R/T surgery of elbow AEB pain 9/10, grimacing face, gripping bed rail & using oxycodone Q4H.
Behavioral Outcome: The patient will report a controlled tolerable pain score of 5/10 on the day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/ goals)
Accept and acknowledge patient’s
description of and response to
pain.
(Independent)
Determine patient’s acceptable
level of pain.
(Independent)
Scientific Rationale for Selected
Interventions
“Pain is a subjective experience and
cannot be felt by others” (Doenges
et al., 2010, p. 588).
“Varies with individual and
situation” (Doenges et al., 2010, p.
589).
Implementation Phase (Indicate
what you, the nurse, the
therapist, etc did on the day of
care)
Asked patient to rate pain level
on pain score every hour.
Accepted and documented:
characteristics, onset, location,
duration, severity, triggers and
alleviation of pain based on
patient’s word.
Asked patient their goal of an
acceptable pain level.
Incorporated patient’s goal and
nurse’s goal to find a happy
medium of a goal of 5/10 for a
tolerable pain score.
Evaluation Phase (Note specific
and measurable data you collected
after the intervention to give
evidence if your planned
interventions helped the client)
Patient able to rate pain score
5/10 after medication.
Patient able to describe pain in
detail as: sharp, lingering and on
right elbow, with no complete
alleviating factors.
After relaxing the patient and
relieving some of her anxiety, able
to get the patient to report she was
tolerating her pain much better
than before.
 Provide comfort measures.
(Independent)
Review procedures and
expectations that may cause pain.
(Collaborative)
Administer analgesics, to
maximum dosage as needed
and/or change to another/stronger
pain medication.
(Independent/Dependent)
Outcomes met? Why or Why not? Explain: Patient reported a tolerable, controlled pain of 5/10 at 1330 well after pain medication and comfort
measures. Outcome fully met.
Student Name: Precious White
Nursing Dx #3: Urinary Retention R/T the disruption of nerve impulses between the brain and bladder AEB sensation of full bladder but not being able to void & no output since
surgery.
Behavioral Outcome: Patient will void at least 120ml by 1400-1600 on the day of care.
“To promote nonpharmacological
pain management” (Doenges et al.,
2010, p. 589).
“To reduce concern of the unknown
and associated muscle tissue”
(Doenges et al., 2010, p. 589).
“To maintain acceptable level of
pain. Notify physician if regimen in
inadequate to meet pain control
goal” (Doenges et al., 2010, p. 590).
Cedar Crest College - Nursing Concept Map (page 4)
Attach Clinical prep sheet to this form
Suggested for the patient to
watch some television to get her
mind off things.
Repositioned to get patient a bit
more comfortable.
Offered an ear to listen while
also having a nurse presence,
available to patient.
Checked patient’s chart to see if
any procedures were scheduled
for the day.
Notified patient of the
expectations for the day.
Watched the primary nurse give
oxycodone 5mg tablet as well as
notify the patient that she could
have acetaminophen in between
oxycodone dosages to help with
the pain.
Client Initials: L.T.
Patient refused to watch television
but did use her cell phone to call
her mom and husband.
Patient able to have correct and
aligned posture when sitting up in
bed, with a full arm cast.
Patient able to express her feelings
on the situation and
circumstances; ultimately
relieving some stress and anxiety.
Saw that Physical therapy was
scheduled, and that Foley catheter
was already taken out.
Expectations for the day was
discharge pending voiding after
d/c of catheter and physical
therapy clearance.
Patient took oxycodone dosage
and decided to wait for it to “kick
in” to determine whether she
would ask for acetaminophen.
Patient reported a decrease in
pain due to the oxycodone dosage
taken.
Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/ goals)
Review medications
(Independent)
Ascertain whether patient has a
full bladder sensation and the
level of comfort associated.
(Independent)
Investigate the inability and
difficulty to pass urine.
(Dependent)
Assist patient to sit upright on
commode or stand over toilet.
(Independent)
Scientific Rationale for Selected
Interventions
“Noting those that can cause or
exacerbate retention” (Doenges et al.,
2010, p. 894).
“Sensation and discomfort can vary,
depending on underlying cause of
retention” (Doenges et al., 2010, p.
895).
“May indicate a UTI or obstruction”
(Doenges et al., 2010, p. 894).
“To provide functional position of
voiding” (Doenges et al., 2010, p. 895).
Implementation Phase
(Indicate what you, the nurse,
the therapist, etc did on the
day of care)
Looked at patient’s current list
of medications and ruled out
that any of them would be
causing urinary retention.
Asked patient what exactly she
was feeling regarding her
bladder, the level of comfort
and whether she feels the urge
to go.
Waited for CBC and other lab
results to come in.
Checked the lab results for any
infections and/or anything
that looked alarming.
Offered patient assistance
while using the bathroom.
Evaluation Phase (Note specific
and measurable data you collected
after the intervention to give
evidence if your planned
interventions helped the client)
Took into consideration the fact
that patient just had surgery the
prior day which included
anesthesia; which can cause
acute/short-term urinary
retention.
Believed that voiding will occur,
given a bit more time after the
surgery.
Patient did not void with more
time given by 1400-1600.
Patient stated, “I feel like I have
to, I just can’t!” Patient attempted
to void multiple times and was
unsuccessful. Patient described
her level of comfort as “bearable
without any striking pain.”
Obtained a BUN of 5, AST of 48
and ALT of 56 with no signs of
infection from lab results. A low
BUN may indicate liver
disease/damage. Patient just had
surgery and haven’t voided,
therefore may be displaying a low
BUN.
AST/ALT are blood liver tests that
may also indicate liver
damage/injury; but should be
looked at pertaining to the whole
individual and not just the lab
values by themselves.
Patient refused the help and was
able to sit up right on the toilet by
herself; still unsuccessful in an
attempt to void.
 Determine stress and anxiety “Patient may be too embarrassed to Implemented therapeutic Patient expressed her anxiety of
level. void in presence of others” (Doenges communication to establish a being in the hospital as well as
(Independent) et al., 2010, p. 895). rapport with the patient. having surgery. Patient stated
“Everything is just wrong. Nothing
is going my way. Life isn’t on my
side.”

Anxiety and stress level did not

influence patient’s ability to void.
Patient was not embarrassed to
attempt to void in the presence of
the nurse.
Outcomes met? Why or Why not? Explain: Patient not able to successfully void after d/c of Foley catheter by 1400-1600, even with all given
interventions. Outcome not successfully met.

Cedar Crest College - Nursing Concept Map (page 5)

Attach Clinical prep sheet to this form
Student Name: Precious White Client Initials: L.T.
Nursing Dx # 4: Risk for Falls R/T postoperative conditions
Behavioral Outcome: The patient will remain free of injury from falls throughout the whole day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/ goals)
Evaluate patient’s cognitive status.
(Independent)
Consider environmental hazards
in the hospital setting.
(Independent)
Scientific Rationale for Selected
Interventions
“Affects ability to perceive own
limitations or recognize danger”
(Doenges et al., 2010, p. 335).
“Identifying needs or deficits
provides opportunities for
intervention and/or instruction”
(Doenges et al., 2010, p. 335).
Implementation Phase (Indicate Evaluation Phase (Note specific
what you, the nurse, the therapist,and measurable data you collected
etc did on the day of care) after the intervention to give
evidence if your planned
interventions helped the client)
Asked the patient their: name, Patient stated her name, DOB,
DOB, location and reason for that she was at the hospital and
being in the hospital. that she had surgery on her right
elbow. It was determined that
patient was alert and oriented x4
and able to follow command
without difficulty.
Made sure all wires, machines, any Patient able to safely and
assistive devices and clutter were effectively maneuver throughout
cleared of all pathways. the room and to the bathroom
without any obstructions.
Made sure the bed rails were up
and that patient’s bed was in the Patient able to sit up in bed safely
lowest position. knowing that her bed was low to
the ground and that bed rails were
there as a safeguard.
 Refer to rehabilitation team,
physical or occupational therapy.
(Collaborative)
Review results of fall risk
assessment.
(Independent)
“To improve patient’s balance,
strength, or mobility; to improve
or relearn ambulation; to identify
and obtain appropriate assistive
devices for mobility” (Doenges et
al., 2010, p. 336).
“Recognize that risk factors for
falling include recent history of
falls, fear of falling, confusion,
depression, altered elimination
patterns and altered mobility”
(Ladwig et al., 2014, p. 341).
Primary nurse asked PT when they
would be working with patient.
Primary nurse the night before
performed a Fall Risk assessment
and notified next shift nurse.
Patient able to adhere to PT
sessions, consisting of getting
OOB and some ROM.
Resulted in a Fall Score of 13,
therefore patient had to wear a
Fall Risk bracelet as well as have a
Fall Risk identifier outside her
door; both for her own good as
well as the nurse’s knowledge.

Assist an immobile patient getting “When rising from a lying Obtained a set of orthostatic BP’s Orthostatic BP’s did not drop from
up. position, have the patient change as well as had patient dangle legs supine to sitting to standing and
(Independent) positions slowly, dangle legs, and and stand up slowly before did not cause any dizziness while
to stand next to bed before walking. standing; therefore, patient was
walking to prevent orthostatic given the permission to ambulate
hypotension” (Ladwig et al., 2014, Used a gait belt to assist patient in while being assisted with a nurse
p. 342). ambulating. utilizing the gait belt.
Outcomes met? Why or Why not? Explain: All safety measures were taken to prevent falls, thus yielding no incidents of falls for the patient while in
the hospital on the day of care. Outcome fully met.
 References

Doenges, M. E., Moorhouse M. F., & Murr, A. C. (2010). Nurse’s pocket guide: Diagnoses, prioritized

interventions, and rationales (12th ed.). Philadelphia, PA: F.A Davis Company.

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2015). Pharmacology: A patient- centered nursing process

approach (8th ed.). St. Louis, MO: Saunders.

Ladwig, G. B., Ackley, B. J., & Makic, M. F. (2014). Mosby’s guide to nursing diagnosis (5th ed.). St. Louis,

MO: Elsevier, Inc.

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing: Concepts, skills & reasoning. Philadelphia, PA: F.A.

Davis Company.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Davis’s drug guide for nurses (15th ed.). Philadelphia,

PA: F.A Davis Company.

Student Name: Precious White
Criteria Possib
Points
Approved NANDA
Nursing Diagnoses
with related to factors
(no medical diagnoses)
are clearly written in the
“A” section of SOAP - All
actual nursing diagnoses
must have an AEB
statement
Client stressors are
prioritized.
Supporting subjective
and objective data
provide evidence to
validate selected
nursing diagnosis.
Student nurse's
physical assessment
findings of the
patient must be
included.
An appropriate general
goal is written for each
nursing diagnosis in the
“P” section of SOAP
A behavioral outcome
is written for each
nursing diagnosis using
Date: 11/23/16 Grading Rubric for NUR 309 Concept Map
Concept Map Assignment
Rating Stude
le nt
Score
18 - 16.2 16.1 - 14.4 14.3 - 12.6 12.5 - 0
18 Includes 4 NANDA Includes 3 NANDA Includes 2 NANDA Includes 1 or no 18
approved nursing approved nursing approved nursing NANDA approved
diagnoses with related diagnoses with related diagnoses with related nursing diagnoses
to factors that are not to factors that are not to factors that are not with related to
medical diagnoses. medical diagnoses. medical diagnoses. factors that are not
medical diagnoses
3 – 2.70 2.6 – 2.4 2.3 – 2.1 2-0
3 All 4 client stressors 3 client stressors are 2 client stressors are Less than 2 stressors 3
are prioritized. prioritized. prioritized. are prioritized.
17 – 15.3 15.2 – 13.6 13.5 – 11.9 11.8 - 0
17 6 to 7 examples of 4 to 5 examples of 2 to 3 examples of valid 1 to 0 examples of 17
valid supporting data valid supporting data supporting data are valid supporting
are written for each are written for each written for each data are written for
nursing diagnosis. nursing diagnosis. nursing diagnosis. each nursing
diagnosis.
8.0 – 7.2 7.1 – 6.4 6.3 – 5.6 5.5 - 0
8 Includes 4 general Includes 3 general Includes 2 general Includes less than 2 8
appropriate goals appropriate goals appropriate goals appropriate general
noted in correct noted in correct noted in correct goals noted in
location. location. location. correct location.
12 – 10.8 10.7 – 9.6 9.5 – 8.4 8.3 - 0
12 Includes 4 appropriate Includes 3 appropriate Includes 2 appropriate Includes less than 2 12
and correctly written and correctly written and correctly written appropriate and
behavioral outcomes. behavioral outcomes. behavioral outcomes. correctly written
 objective & measurable
terms.
10 - 9
Priority Nursing 10 Includes 5 priority
interventions are nursing interventions
planned and are correctly written for each
identified as nursing diagnosis.
independent, dependent, All nursing
or collaborative. interventions are
correctly identified as
independent,
dependent, or
collaborative.
10 - 9
Planned & 10 All nursing
Implemented interventions are
Nursing directly related to
interventions are meeting the selected
directly related to behavioral outcome.
meeting the selected
behavioral outcome.
5 – 4.5
Valid Scientific 5 Includes valid
Rationale is provided scientific rationale for
for all nursing all planned nursing
interventions. interventions.
15 – 13.5
Evaluation of 15 All Client responses
effectiveness of include subjective
implemented and/ or objective
interventions is assessment findings
supported by client that give evidence of
responses to care. effectiveness of care.
behavioral
outcomes.
8.9 - 8 7.9 – 7 6.9 - 0
Includes 4 priority Includes 3 priority Includes less than 3 10
nursing interventions nursing interventions priority nursing
written for each written for each interventions
nursing diagnosis. nursing diagnosis. written for each
3/4 th of the total 1/2 of the total nursing diagnosis.
number of nursing number of nursing 1/4th or less of the
interventions are interventions are total number of
correctly identified as correctly identified as nursing
independent, independent, interventions are
dependent, or dependent, or correctly identified
collaborative. collaborative. as independent,
dependent, or
collaborative.
8.9 - 8 7.9 – 7 6.9 - 0
3/4th of the Total ½ of the Total number 1/4th or less of the 9
numbers of nursing of nursing Total number of
interventions are interventions are nursing
directly related to directly related to interventions are
meeting the selected meeting the selected directly related to
behavioral outcome. behavioral outcome. meeting the selected
behavioral outcome.
4.4 – 4 3.9 – 3.5 3.4 - 0
Includes valid Includes valid scientific Includes valid 5
scientific rationale for rationale for 1/2 of the scientific rationale
3/4th of the Total Total number of for less than 1/4th of
number of planned planned nursing the Total number of
nursing interventions. interventions. planned nursing
interventions.
13.4 – 12 11.9 – 10.5 10.4 - 0
3/4th Client responses ½ Client responses Less than 1/4th of 14
include subjective include subjective and/ Client responses
and/or objective or objective assessment include assessment
assessment findings findings that give findings that give
that give evidence of evidence of evidence of
effectiveness of care. effectiveness of care. effectiveness of care.
 2 – 1.8 1.7 – 1.6 1.5 – 1.4 1.3 - 0
Supporting materials are 2 No supporting 1/3rdsupporting 2/3rdsupporting All supporting 2
submitted with materials are materials are materials are materials are
assignment. (Supporting submitted with submitted with submitted with submitted with
materials include assignment. assignment. assignment. assignment.
1.clinical prep sheet, 2.
grading rubric and 3. APA format is
reference page for 5 or more unique APA 3-4 unique APA 1-2 unique APA errors. without error.
scientific rationale.) errors. errors.

Total points 98/

100
Note: Max points = 100