Brookfield Kenosha Adult Health Care Plan Template
Brookfield Kenosha Adult Health Care Plan Template
Case Study Assignment Instructions
Purpose
As you are learning this semester, the role of the nurse is to integrate and apply knowledge from your general education background, health related sciences, and evidence-based nursing science in the application of the nursing process to the nursing care of patients in the acute care setting. The nurse uses knowledge from pharmacology, anatomy and physiology, pathophysiology, microbiology, nutrition, psychology, and other sciences to build a plan of care according to the health assessment findings generated by the nurse. Nursing is practiced within an interdisciplinary health care system, and it is important for the nurse to understand the perspectives of other disciplines in their contribution to the patient plan of care. For this assignment, you will use the case study provided or choose a client from your clinical rotation. You will complete an in-depth analysis of the nature of their health alterations, the pathophysiological and psychosocial aspects of their health needs and how the interdisciplinary team contributes to the treatment plan while the patient is in the hospital and as plans for discharge are put into action.
Directions
- Read the information about the case study with the chart materials provided or gather the necessary information from one of your patients.
- Review the patient assessment information. What other assessments might you do in addition to those provided? What findings would you anticipate with this patient? Develop a care plan (use the template below) based on the highest priority problem (1 nursing diagnosis, 1 goal, 3 interventions for each goal, 1 rationale for each intervention and evaluation for each goal). Complete an in depth analysis reflecting your ability to prepare a case study based on principles derived from pharmacology, pathophysiology, psychology, nutrition, and evidence-based nursing practice guidelines. Remember to include an introduction to the patient, pathophysiology, history, nursing assessment (given and any additional), and related treatments.
- Include selected references for your case study paper/care plan and use APA format.
- Specific grading rubric is provided.
Criteria
Case study is specific, analytical, conceptually sound and based on scientific principles and application of knowledge, reflects evidence-based nursing care approaches and science, and is holistic in its approach to understanding the patient and his/her nursing care needs.
Estimated time to complete: 6 hours
Attached Files
Rubric
NU302 Care Plan Rubric
NU302 Care Plan Rubric
| Criteria |
Ratings |
Pts |
| This criterion is linked to a Learning OutcomeIntroduction to Patient |
| 10.0 pts5
Clearly explains who the patient is (age, gender, etc.), what the problem is, and what you are focusing on regarding care of this patient. |
9.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
8.0 pts3
Vaguely explains who the patient is, what the problem is, and what you are focusing on regarding care of this patient; missing 1 of above areas |
7.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
6.0 pts1
Lack of introduction to the patient; missing 2 or more areas in first 2 columns of this row. |
0.0 pts0
Not attempted/not submitted |
|
10.0 pts |
| This criterion is linked to a Learning OutcomePathophysiology |
| 10.0 pts5
Clearly and concisely discusses the disease, manifestations, and causes. |
9.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
8.0 pts3
Vaguely or missing minimal information regarding the disease, manifestations, and causes. |
7.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
6.0 pts1
Missing important information regarding the disease, manifestations, and causes. |
0.0 pts0
Not attempted/not submitted |
|
10.0 pts |
| This criterion is linked to a Learning OutcomeHistory |
| 10.0 pts5
Clearly and concisely discusses patient’s health history & past treatments including prior surgeries and prescribed medications. |
9.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
8.0 pts3
Vaguely discusses patient’s health history & past treatments including prior surgeries and prescribed medications. |
7.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
6.0 pts1
Missing important information regarding the patient’s health history & past treatments including prior surgeries and prescribed medications. |
0.0 pts0
Not attempted/not submitted |
|
10.0 pts |
| This criterion is linked to a Learning OutcomeRelated Treatments |
| 20.0 pts5
Clearly and concisely explains what treatments the patient is receiving because of his/her disease. |
18.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
16.0 pts3
Vaguely explains what treatments the patient is receiving because of his/her disease. |
14.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
12.0 pts1
No explanation of treatment(s) patients is receiving because of his/her disease. |
0.0 pts0
Not attempted/not submitted |
|
20.0 pts |
| This criterion is linked to a Learning OutcomeCare Plan |
| 20.0 pts5
Contains nursing diagnosis, 1 SMART outcome, 3 SMART interventions with appropriate rationales, and evaluation. |
18.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
16.0 pts3
Missing 1 part of diagnosis or 1-2 SMART outcomes and interventions; may not be the best nursing diagnosis. 1 rationale is not related to intervention. |
14.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
12.0 pts1
Inappropriate nursing diagnosis; lacking SMART outcomes and interventions. Rationales not supportive of interventions. |
0.0 pts0
Not attempted/not submitted |
|
20.0 pts |
| This criterion is linked to a Learning OutcomeNursing Physical Assessment |
| 20.0 pts5
Clearly and concisely lists all patient’s assessment data in sentences with specific numbers/levels. |
18.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
16.0 pts3
Vaguely lists all patient’s assessment data; lacking some sentences; lacking some specific numbers/levels. |
14.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
12.0 pts1
Missing important assessment data; lacking sentences and specific numbers/levels. |
0.0 pts0
Not attempted/not submitted |
|
20.0 pts |
| This criterion is linked to a Learning OutcomeAPA Formatting and References and Scholarly WritingPRICE-I |
| 10.0 pts5
Utilizes 1st and 2nd level headings appropriately; at least 3 pages long; 2 credible resources; appropriate in text citations. Scholarly writing is evident. |
9.0 pts4
Contains both elements of High Proficiency and Moderate Proficiency |
8.0 pts3
Utilizes headings but not accurately placed; minor errors in citations and referencing. Some errors in sentence structure/grammar. |
7.0 pts2
Contains both elements of Moderate Proficiency and Non- Proficient |
6.0 pts1
Lacks headings; < 3 pages long; lacks references and in text citations. Poor grammar and sentence structure evident. |
0.0 pts0
Not attempted/not submitted |
|
10.0 pts |
| Total Points: 100.0 |
