Download draft - Cuesta College

RUBRIC FOR 2nd SEMESTER CASE STUDIES
CASE STUDIES TURNED IN LATE WILL BE GRADED DOWN 1 GRADE FOR EVERY DAY LATE
INTRODUCTION (5 points):
 The description of the client and their demographics is clear, direct and does not leave any questions.
 There is a clear description of the events leading to this hospitalization. It includes the client’s present medical
problems. There is clear data to help support the identified priority of nursing diagnoses.
 It is clear why the student chose this client for case study based on nursing focused learning opportunities not
emotional attachment and/or interesting medical diagnosis.
 It is concise and no more than 2 pages.
 Addresses cultural, spiritual, and growth and development issues.
 Active medical/surgical diagnoses are defined clearly and concisely including how the disease manifested itself
in the selected client.
 Past medical history (as it relates to current client status) is identified, including definition of pertinent
diagnoses.
 References support the student’s interpretation of the data and are appropriate and well integrated.
ASSESSMENT (10 points)
 All systems (head to toe) and elements of assessment are addressed, using the Cuesta College format.
Assessment findings that support identified nursing diagnoses and medical problems are evident, easily
identified and supported by medical/medication orders. Priority is given to documenting supporting assessment
findings/abnormal assessment findings before normal findings within each system.
 Assessment includes appropriate baseline data for comparison ie: baseline B/P for client with elevated B/P.
 Assessment is written in concise format using proper medical terminology.
 Includes pertinent psycho-social assessment addressing client’s perception of current health status, mood/affect.
MEDICATION INFORMATION (10 points)
 All medications ordered for the client are identified (includes prn medications) with dose, frequency, route. The
Cuesta College drug information form is used. All medications are appropriately referenced.
 Classification and dosage range are identified. Rationale for lower than normal or higher than normal dosage
ranges are included. Math calculations are done as appropriate ie: if safe dose is expressed as mg/Kg/day the
math is done to indicate client is receiving a safe dose.
 Why the client is receiving the medication is clearly delineated ie: pain related to rheumatoid arthritis affecting
hands and legs versus stating pain. Relationships are draw between assessment data, medical diagnosis,
relationship to other medications.
 Nursing implications are appropriately complete and relevant to the client. Pertinent lab values if available are
identified. Client teaching is appropriate to the setting and client’s cognitive ability.
 Evaluation of effects of medications is concise and complete including appropriate assessment findings and
pertinent lab values. Evaluation of client response includes data related to important potential adverse effects.
MEDICAL CARE AND RATIONALE (5 points)
 List of medical orders is complete.
 Rationale for medical orders is accurate and consistent with medical diagnoses and assessment findings.
LABORATORY DATA (10 points)
 All laboratory data relevant to client’s diagnosis and medication regime are identified.
 Reference values are noted. Relevant trends are noted.
 Interpretation of lab values is accurate and correlates with diagnosis, medication regime and assessment
findings.
NURSING CARE PLANS (50 points: Nursing Diagnoses List =10 points; Care Plan Dx=13.3 points each)
Nursing Diagnosis List: Ten high priority nursing diagnoses are listed for client and are organized in order of
priority by placing the most significant problem first, followed by the second most significant and meet the
following guidelines
 Actual nursing diagnoses are written correctly as three part statements
 Risk for nursing diagnoses are written correctly as two-part statements:
 The first part of the diagnostic statement (problem) is a NANDA-approved diagnosis that accurately describes
the client’s problem and for which the client problem meets the defining characteristics
 Second part of the statement (etiology) accurately identifies factors causing or contributing to an actual
problem, or the risk factors for a risk problem.
 Third part of the statement (signs and symptoms) are defining characteristics that describe and validate the
selected diagnosis.
 If a medical diagnosis is used to add clarity to the nursing diagnosis, it is linked to the statement as secondary
to the second part of the statement as in the following example:
“Chronic pain related to tissue trauma secondary to arthritis as manifested by red, swollen, warm joints and
pain.”
Nursing Care Plans: The three highest priority nursing diagnoses are developed into a nursing care plan.
 Outcome Criteria:
 For each nursing diagnosis, there is a realistic, individualized and measurable goal identified.
 Each goal contains a subject, an action verb, performance criteria and a target time. Achievement of the goal
clearly demonstrates resolution or reduction of the identified problem.
 Nursing interventions: For each nursing diagnosis there is a minimum of six written, detailed interventions.
 Interventions should reflect appropriate integration of psychomotor, cognitive and interpersonal nursing
skills as indicated to address the maturational, cultural and spiritual needs of the client.
 Interventions provide clear guidelines and specify what is to occur and who is to perform the action and
meet the following criteria:
 Refer to the “related to” component of the actual nursing diagnosis statement or to
 the risk factors in risk nursing diagnoses (if the nursing interventions can remove or reduced the related
factors and the risk factors, the problem can be resolved or prevented)
For example, with a nursing diagnosis of “Impaired physical mobility related to joint pain and
stiffness secondary to arthritis as manifested by range of motion limitations” interventions
selected will reduce or eliminate stiffness and pain. .
 Assist or enable the client to achieve the results specified by the goals and expected outcomes.
 Clearly state the necessary action and note who is to perform the intervention and when and how it is to
be implemented. For example,
“Promote comfort” doesn’t say what specific action to take but “RN to administer ordered
analgesic ½ hour before dressing change” describes exactly who is to perform the intervention,
what is to be done and when to do it.
 Are individualized to the patient and consider the client’s age, condition, cognitive ability,
developmental level, environment and values
 Scientific Rationale: Interventions are followed by a scientific rationale supporting selection of the
intervention.
 The rationale is stated completely and is able to stand alone. For example, consider the following
examples of two rationale provided to support an intervention directed towards addressing a nursing
diagnosis of sleep pattern disturbance, “Avoid caffeine-containing foods and beverages during
afternoon and evening”
 Incomplete rationale statement: R: Can produce wakefulness (Carpenito, 2000)
 Complete rationale statement: R: Caffeine is a central nervous system stimulant that lengthens
sleep latency and increases nighttime wakening (Carpenito, 2000)
Evaluation:
 Evaluative statements clearly describe that the goal was met, partially met or not met. If the goal was either
partially met or not met, a thoughtful review of the care plan components is provided to assess why the plan
was not effective.
 Based on this review, how the student would revise the care plan to enhance goal achievement if the plan
were to be re-implemented.
CONCLUSION (5 points)
 Clearly delineates what was learned from developing the case study related to nursing process and the role of
the nurse. Includes insights regarding how what was learned has influenced their own personal practice.
Includes the impact of the care they provided on their client and the client’s response. Includes appropriate
citations/references which are integrated into paper.
 Concise. No more than one page.
APA FORMAT (5 points)
 No APA format errors. 1 or two minor typos maximum.
 No spelling errors. No grammatical or syntax errors.
 Includes required number of citations/references. All citations are noted in reference list and vice-versa.
 Citations/references are from recognized nursing journals and texts. Medical sources can be used but are
additive to required number.
 Nursing journals no more than three years old. Texts are no more than five years old.