Description
Patient information and the CJP documents are attached.
I wrote everything that was in the chart. if there are things missing, plz make things up as long as the boxes are full.
NURS 481L Clinical Judgment Plan Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeHistory of present illness (HPI) and comprehensive clinical examination/review of systems (ROS)
16 pts
Proficient
Explains HPI and ROS in detail with clear and accurate understanding of chief complaint. Evidence-based rationales clearly and accurately support the HPI and ROS.
12.16 pts
Acceptable
Explains HPI and ROS in some detail with adequate understanding of chief complaint. Evidence-based rationales adequately support the HPI and ROS.
9.6 pts
Needs Improvement
Explains HPI and ROS in limited detail with limited understanding of chief complaint. Evidence-based rationales vaguely support the HPI and ROS or are not present.
0 pts
Unsatisfactory
Fails to explain HPI and ROS with poor understanding of chief complaint. Evidence-based rationales do not support the HPI and ROS or are not present.
16 pts
This criterion is linked to a Learning OutcomePathophysiology of admitting diagnosis and past medical/surgical histories
16 pts
Proficient
Clearly and accurately explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Clearly and accurately associates specific details related to the client’s history and signs/symptoms with evidence-based citations.
12.16 pts
Acceptable
Adequately explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Adequately associates specific details related to the client’s history and signs/symptoms with evidence-based citations.
9.6 pts
Needs Improvement
Vaguely explains the pathophysiology for each admitting diagnosis and past medical/surgical history. Vaguely associates specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.
0 pts
Unsatisfactory
Fails to provide pathophysiology of admitting diagnosis and past medical/surgical history. Does not associate specific details related to the client’s history and signs/symptoms with limited to no evidence- based citations.
16 pts
This criterion is linked to a Learning OutcomeSocioeconomic/psychosocial assessment
8 pts
Proficient
Clearly and accurately describes socioeconomic and psychosocial background in detail with evidence-based citations. Identifies at least 3 or more psychosocial concerns.
6.08 pts
Acceptable
Adequately describes socioeconomic and psychosocial background in detail with evidence-based citations. Identifies at least 2 psychosocial concerns.
4.8 pts
Needs Improvement
Vaguely describes socioeconomic and psychosocial background in detail with limited to no evidence-based citations. Identifies at least 1 psychosocial concern.
0 pts
Unsatisfactory
Fails to describe socioeconomic and psychosocial background with limited to no evidence- based citations. Identified no psychosocial concerns.
8 pts
This criterion is linked to a Learning OutcomeTeaching assessment & client education
8 pts
Proficient
Clearly and accurately identifies areas of instructional needs, learning preference, and learning barriers. Provided clear and concise client education that will aid in health promotion, health maintenance and self-care activities.
6.08 pts
Acceptable
Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education that aids in health promotion, health maintenance and self-care activities.
4.8 pts
Needs Improvement
Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education that will aid in health promotion, health maintenance and self-care activities.
0 pts
Unsatisfactory
Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education that will aid in health promotion, health maintenance and self-care activities.
8 pts
This criterion is linked to a Learning OutcomeInterprofessional consults and collaborative plan
8 pts
Proficient
Lists at least 3 appropriate collaborative issues/concerns. Evidence- based rationales demonstrate clear and accurate understanding of consults and interventions.
6.08 pts
Acceptable
Lists at least 2 appropriate collaborative issues/concerns. Evidence- based rationales demonstrate adequate understanding of consults and interventions.
4.8 pts
Needs Improvement
Lists at least 1 appropriate collaborative issue/concern. Evidence-based rationales demonstrate vague understanding of consults and interventions or may be missing.
0 pts
Unsatisfactory
Fails to list collaborative issues/concerns or lists issues/concerns that are inappropriate. Evidence- based rationales demonstrate unsatisfactory understanding of consults and interventions or may be missing.
8 pts
This criterion is linked to a Learning OutcomeMultidisciplinary client outcome and discharge planning/referrals
8 pts
Proficient
Clearly and accurately describes issues/concerns related to multidisciplinary discharge planning with evidence-based rationales.
6.08 pts
Acceptable
Adequately describes issues/concerns related to multidisciplinary discharge planning with evidence- based rationales.
4.8 pts
Needs Improvement
Vaguely describes issues/concerns related to multidisciplinary discharge planning with limited to no evidence-based rationales.
0 pts
Unsatisfactory
Fails to describe issues/concerns related to multidisciplinary discharge planning with limited to no evidence-based rationales.
8 pts
This criterion is linked to a Learning OutcomeLabs
8 pts
Proficient
Clearly and accurately identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with evidence- based rationales.
6.08 pts
Acceptable
Adequately identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with evidence- based rationales.
4.8 pts
Needs Improvement
Vaguely identifies pertinent laboratory tests with applicable indications, addresses abnormal values, and recognizes trends related to a client’s disease process with limited to evidence-based rationales.
0 pts
Unsatisfactory
Fails to identify pertinent laboratory tests with applicable indications, address abnormal values, or recognize trends related to a client’s disease process with limited to no evidence-based rationales.
8 pts
This criterion is linked to a Learning OutcomeDiagnostics/procedures
8 pts
Proficient
Clearly and accurately describes the client’s diagnostic criteria and indications with evidence- based rationales that clearly support the chief complaint and presenting signs/symptoms.
6.08 pts
Acceptable
Adequately describes the client’s diagnostic criteria and indications with evidence-based rationales that adequately support the chief complaint and presenting signs/symptoms.
4.8 pts
Needs Improvement
Vaguely describes the client’s diagnostic criteria and indications with limited to no rationales which vaguely support the identified chief complaint and presenting signs/symptoms.
0 pts
Unsatisfactory
Fails to describe the client’s diagnostic criteria and indications with limited to no rationales and does not support the identified chief complaint and presenting signs/symptoms.
8 pts
This criterion is linked to a Learning OutcomeMedications
16 pts
Proficient
Clearly and accurately identifies all components of the medication list with evidence-based citations, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client.
12.16 pts
Acceptable
Adequately identifies some components of the medication list with evidence-based citations, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client.
9.6 pts
Needs Improvement
Vaguely identifies few components of the medication list with limited to no evidence-based citations, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client.
0 pts
Unsatisfactory
Fails to identify all components of the medication list with limited to no evidence-based citations, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client.
16 pts
This criterion is linked to a Learning OutcomeRecognition of cues
16 pts
Proficient
Identifies at least 4 or more imperative assessment cues. All cues are relevant. Evidence-based citations clearly and accurately support the cues.
12.16 pts
Acceptable
Identifies at least 2 imperative assessment cues. Some cues are relevant. Evidence-based citations adequately support the cues.
9.6 pts
Needs Improvement
Identifies at least 1 imperative assessment cue. Few cues are relevant. Evidence-based citations vaguely support the cues or are missing.
0 pts
Unsatisfactory
Fails to identify imperative assessment cues. Cues are not relevant. Evidence- based citations are limited or are missing.
16 pts
This criterion is linked to a Learning OutcomeAnalysis of cues
16 pts
Proficient
The analysis of cues clearly and accurately supports the prioritized client needs and plan of care. Clearly and accurately links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. All cues are analyzed with evidence- based citations.
12.16 pts
Acceptable
The analysis of cues adequately supports the prioritized client needs and plan of care. Adequately links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. Some cues are analyzed with evidence- based citations.
9.6 pts
Needs Improvement
The analysis of cues vaguely supports the prioritized client needs and plan of care. Vaguely links cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. Few cues are analyzed with limited to no evidence-based citations.
0 pts
Unsatisfactory
Fails to analyze cues or does not support the prioritized client needs and plan of care. Fails to link cues to a patient’s clinical presentation in establishing probable patient needs, concerns, or problems. No cues are analyzed or do not have evidenced-based citations.
16 pts
This criterion is linked to a Learning OutcomePrioritization of hypotheses (clinical judgments)
16 pts
Proficient
Identifies at least 4 nursing clinical judgements that are clear, accurate, and prioritized with clear etiology and data to support rationale. The clinical decision is clear, accurate, and presents correlation from the recognized cues based on priority-setting frameworks.
12.16 pts
Acceptable
Identifies at least 4 nursing clinical judgments that are adequate and prioritized with sufficient etiology and data to support rationale. The clinical decision is adequate and presents correlation from the recognized cues based on priority-setting frameworks.
9.6 pts
Needs Improvement
Identifies less than or equal to 4 nursing clinical judgments that are vague and not prioritized with insufficient etiology and data to support rationale. The clinical decision is vague and may or may not have correlation from the recognized cues based on priority-setting frameworks or is missing.
0 pts
Unsatisfactory
Fails to identify nursing clinical judgments or is not prioritized with insufficient etiology and data to support rationale. Fails to identify clinical decisions with no correlation from the recognized cues based on priority-setting frameworks.
16 pts
This criterion is linked to a Learning OutcomeGeneration of solutions (S.M.A.R.T goals/outcomes)
16 pts
Proficient
Clearly and accurately establishes client’s goal/outcome criteria that can be achieved with nursing assistance. The goal/outcomes clearly and accurately support the clinical judgments and plan of care. All goals/outcomes are time-limited to the date/time of care and are specific, measurable, attainable, and relevant.
12.16 pts
Acceptable
Adequately establishes client’s goal/outcome criteria that can be achieved with nursing assistance. The goal/outcomes adequately support the clinical judgments and plan of care. Some goals/outcomes are time-limited to the date/time of care and are specific, measurable, attainable, and relevant.
9.6 pts
Needs Improvement
Vaguely establishes client’s goal/outcome criteria that may be achieved with nursing assistance. The goal/outcomes vaguely support the clinical decisions and plan of care. Few goals/outcomes are time- limited to the date/time of care and may or may not be specific, measurable, attainable, and relevant.
0 pts
Unsatisfactory
Fails to establish client’s goal/outcome criteria that may be achieved with nursing assistance. The goal/outcome does not support the clinical decisions and plan of care. Goals/outcomes are not time-limited to the date/time of care and are not specific, measurable, attainable, or relevant.
16 pts
This criterion is linked to a Learning OutcomeImplementation of actions (interventions)
16 pts
Proficient
Clearly and accurately identifies at least 16 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. All interventions are individualized, prioritized, specific, and with timed frequencies. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.
12.16 pts
Acceptable
Adequately identifies at least 14 to 16 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. Some interventions are individualized, prioritized, specific, and with timed frequencies. Nursing actions are adequately aimed at the client’s goals and sometimes directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.
9.6 pts
Needs Improvement
Vaguely identifies at least 12 to 14 actions that are independent nursing interventions that may or may not be supported by scientific rationale and evidence-based practice. Few interventions are individualized, prioritized, specific, and may or may not notate timed frequencies. Nursing actions are vaguely aimed at the client’s goals and may or may not be directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.
0 pts
Unsatisfactory
Fails to identify at least 12 actions that are independent nursing interventions supported by scientific rationale and evidence-based practice. Interventions are not individualized, prioritized, specific, or do not have timed frequencies. Nursing actions are not aimed at the client’s goals and are not directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development.
16 pts
This criterion is linked to a Learning OutcomeEvaluation
16 pts
Proficient
Clearly and accurately identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is clearly and accurately linked to the generated solutions and overall plan of care. Modifies, revises, and recommends alternative intervention(s) with evidence-based citations as applicable.
12.16 pts
Acceptable
Adequately identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is adequately linked to the generated solutions and overall plan of care. Modifies, revises, and recommends alternative intervention(s) with evidence-based citations as applicable.
9.6 pts
Needs Improvement
Vaguely identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is vaguely linked with generated solutions and overall plan of care. May or may not modify, revise, or recommend alternative intervention(s) with limited to no evidence-based citations as applicable.
0 pts
Unsatisfactory
Fails to identify criteria for evaluation, effectiveness of interventions, and measurement of goal completion. Evaluation is not linked with generated solutions and overall plan of care. Does not modify, revise, or recommend alternative intervention(s) with limited to no evidence- based citations as applicable.
16 pts
This criterion is linked to a Learning OutcomeGeneral Organization
8 pts
Proficient
Clear and accurate APA format. Concisely appropriate citations and references. No spelling or grammar errors.
6.08 pts
Acceptable
Adequate APA format. Adequate appropriate citations and references, Few spelling or grammar errors.
4.8 pts
Needs Improvement
Inadequate APA format. Inappropriate citations and references. Some spelling or grammar errors.
0 pts
Unsatisfactory
Fails to utilize APA format. No appropriate citations and references. Many spelling or grammar errors.
8 pts
Total Points: 200
Unformatted Attachment Preview
Student Name
Clinical Judgement Plan
West Coast University
Professor Name
Date:
LB/DW/CB revised 3/30/23
Date:
Student Name:
Instructor:
Patient Information (1)
Name:
Age: Age in years/not DOB
Gender:
Code Status:
DPOA:
Living Will:
Allergies:
History of Present Illness (HPI)
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) (SEE RUBRIC REQUIREMENTS)
Pathophysiology of Admitting Dx (minimum of 3-5) (Cite References)
For each disease identified, describe pathophysiology, and any potential complications & cite source.
Chief Complaint
Pathophysiology of Medical History (minimum of 3-5)
For each disease identified, describe pathophysiology, and any potential complications & cite source.
Admitting Diagnosis
Erickson’s Developmental Stage Related
to pt. & Cite References (1)
Surgical History
For each procedure identified, define & describe it; include year of procedure & cite source.
Social History
SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE
Medical Management/ Orders/ Medications & Allergies (2)
Medication Name
Dose
RT
Freq.
MOA
Indications
Side Effects/Adverse
RN Considerations
Identify and explain abnormal findings related to Patient’s disease process
Test
Normal
WBC
4.40-11
Hgb
Hct
Platelets
Na+
K+
Chloride
Co2
Creatinine
Blood
Glucose
BUN
Troponins
BNP
14.0- 16.0
36-42
150-450
135-145
3.5-5.0
95-110
23-29
0.6-1.3
76-106
ALT
Ca+
Albumin
AST
Blood
cultures
Cholesterol
Triglycerides
HDL
LDL
Lactic Acid
Procalcitonin
CEA
CA 125
Pt.
Admit
Labs
8.0-30.0
0.0-0.4
>125pg/m
L
7 to 56
8.5 – 10.5
3.5 – 5.5
10- 40
100 to 129
40 – 59
100 -129
0.5 – 1
0-0.5
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