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Nursing Assignment on Care Plan for Acute Renal injury patient

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Nursing Assignment on Care Plan for Acute Renal injury patient

STUDENT NAME ____________________________________ DATE _______________________
DATE OF CLINICAL EXPERIENCE____________________________ CARE PLAN #___________
Evaluation Criteria Possible
Subjective and Objective Data
Correctly documents patients’ health issues & condition (5), assessment (5)
and interprets labs (10)
Appropriately documents ROS (5) & required medication information (10) 15
Nursing Diagnoses
Identifies 3 appropriate NANDA nursing diagnoses and indicate
priority of each nursing diagnosis
Appropriately states nursing diagnoses, incorporating bio-psycho-social
patient data with logical problem-etiology statement
Goals & Expected Outcomes
Identifies appropriate short-term goal for nursing diagnosis with the highest
priority. Identifies expected outcomes that are short, measurable, attainable,
realistic and timely (SMART)
Nursing Interventions
Lists 5 patient-specific, appropriate, comprehensive, and safe nursing
interventions directly related to the nursing diagnosis and expected outcomes
States scientific rationale, including citation of reference source and page
number for each rationale
Includes teaching & discharge planning in nursing interventions for identified
nursing diagnosis
States whether goals met/partially met/unmet, giving supporting data 2
Evaluation reflects pre-stated goal criteria and specified bio-psycho-social
patient data
Revision of Plan
Revises goals, time frame, and nursing interventions 2
Teaching Plan
Identifies appropriate teaching need for identified patient problem 2
Assesses patient’s knowledge and readiness to learn 2
Writes specific, succinct teaching content (2); states teaching method and
aids to be used for teaching (2) & states whether learning has occurred,
including supportive data; includes teaching goal in measurable format (2)
Uses correct grammar, spelling, and medical terminology 2
Completes a reference page 2
Correctly uses 6th edition APA format for reference citations 2
Incorporates instructor feedback from previous paperwork 2
Submits in a timely fashion as instructed by clinical faculty 2
Faculty: __________________________________________ Date:___________________________
ADDITIONAL COMMENTS: ____________________________________________________________________________

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