Assessment

and

Data Collection

Three NANDA-I Approved Nursing Diagnosis

*Risk: Nursing diagnosis____Related to_____

*Actual: Nursing diagnosis____Related to____ as evidenced by

One Smart Goal for EACH Nursing Diagnosis

*Specific and measurable with a timeline. Find from the nursing diagnosis book (under client or expected outcomes section) and individualize to your patient-ONE SENTENCE

3 Nursing Interventions with Rationale for EACH Nursing Diagnosis

Disease Process: (short description of patho of disorder- cite this):

Common Labwork/Diagnostics:

Assessment Data (consider subjective, objective, and heath history):

Nursing Diagnosis:

Nursing Diagnosis:

Nursing Diagnosis

SMART Goal:

SMART Goal:

SMART Goal:

1.

Rationale:

2.

Rationale:

3.

Rationale:

Cite:

1.

Rationale:

2.

Rationale:

3.

Rationale:

Cite:

1.

Rationale:

2.

Rationale:

3.

Rationale:

Cite:

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Assessment / Data Collection

(10 Pts)

Lacks basic factors of the disease process, common labs, diagnostic tests, and subjective, objective, and health history data.

Failure to submit Assessment/Data Collection will result in zero points for this criterion.

Briefly identifies the factors including the disease process, common labs, diagnostic tests, and subjective, objective, and health history data.

Clearly identifies the factors including the disease process, common labs, and diagnostic tests, and subjective, objective, and health history data.

Thoroughly identifies all factors including the disease process, common labs, diagnostic tests, and subjective, objective, and health history data with a deep understanding.

Points – 7

Points – 8

Points – 9

Points – 10

Nursing Diagnosis (should fit the data)

(10 Pts)

Nursing diagnoses are insufficient and/or do not fit the data.

Failure to submit Nursing Diagnosis will result in zero points for this criterion.

Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a strong connection to identified data.

Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data.

Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data.

Points – 7

Points – 8

Points – 9

Points – 10

SMART Goal (should reflect the diagnosis and follow guidelines)

(15 Pts)

The goals meet few SMART goal guidelines and/or are not related to the nursing diagnoses.

Failure to submit SMART goals will result in zero points for this criterion.

Writes ONE goal for ONE nursing diagnosis and the goal meets all the SMART goal guidelines and are related to the nursing diagnosis.

Writes ONE goal for TWO nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Writes ONE goal for THREE nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Points – 11

Points – 12

Points – 13

Points – 15

Interventions and Rationale

(20 Pts)

Lacks appropriate interventions and rationale to assist the client in resolving the issues leading to the problem.

Failure to submit Interventions and Rationale will result in zero points for this criterion.

Writes 3 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Writes 3 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.

Points – 15

Points – 16

Points – 18

Points –20

APA Citation

(5 Pts)

APA in-text citations and references are missing.

Attempted to use APA in-text citations and references.

APA in-text citations and references are used with few errors.

APA in-text citations and references are used correctly.

Points- 2

Points- 3

Points- 4

Points- 5

Spelling and Grammar

(5 Pts)

Numerous spelling and grammar errors, which detract from the audience's ability to comprehend material.

Some spelling and grammar errors, which detract from the audience's ability to comprehend material.

Few spelling and grammar errors.

Minimal to no spelling and grammar errors.

Points- 2

Points- 3

Points- 4

Points- 5