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Lamar State College Port

Arthur
Upward Mobility Program
RNSG 236 Cli!i"al
Care Pla!
Student: Date: Instructor:
Submit Cli!i"al Care Pla! i! RNSG 236 a##ig!me!t area$
3 %3&2 %2&' Poi!t#
(ar!ed
Appropriate medical terms and/or
abbreviations used throughout
1 - 2 inappropriate medical term
and/or abbreviation used
>2 Inappropriate medical term
and/or abbreviation used
Highest Priority (according to
student) A!A "ully developed
Highest Priority (according to
student) A!A development
incomplete
!eveloped A!A not the highest
priority #ithout preapproval
$ource is documented correctly
using APA "ormat
$ource is not indicated or APA
"ormat is incorrectly used
3 %3&6 %6&' Poi!t#
(ar!ed
%inimum o" & appropriate A!A
problems identi'ed( properly
#ritten( and properly prioriti)ed
1-2 errors in* %inimum o" &
appropriate A!A problems
identi'ed( properly #ritten( and
properly prioriti)ed
>2 errors in* %inimum o" &
appropriate A!A problems
identi'ed( properly #ritten( and
properly prioriti)ed
$ub+ective , ob+ective data
included that are de'ning
characteristics o" nursing diagnosis
-ither sub+ective or ob+ective data
is missing on care plan or data is
not a de'ning characteristic o"
developed nursing diagnosis
$ub+ective or ob+ective data is
missing on care plan and data is
not a de'ning characteristic o"
developed nursing diagnosis
.ell #ritten /oals #hich include*
0our (1) appropriate short term
goals and one (1) long term goals2
outcomes that are* speci'c(
realistic , measurable( a de'nite
time "rame "or achievement( and
consideration o" patient3s desires
, resources
/oals include all but one o" criteria*
appropriate short term and long
term goals2 speci'c( realistic ,
measurable( a de'nite time "rame
"or achievement( and consideration
o" patient3s desires , resources
/oals missing >1 o" criteria*
appropriate short term and long
term goals2 speci'c( realistic ,
measurable( a de'nite time "rame
"or achievement( and consideration
o" patient3s desires , resources
Interventions* relate to the goals2
are speci'c and clearly stated to
include* )ho per*orm#+ how+
whe!+ where+ time,*re-ue!"y+
. amou!t
Interventions include all but o!e o"
criteria* relate to the goals2 are
speci'c and clearly stated to
include* )ho per*orm#+ how+
whe!+ where+ time,*re-ue!"y+
. amou!t
Interventions missing >1 o"
criteria* relate to the goals2 are
speci'c and clearly stated to
include* )ho per*orm#+ how+
whe!+ where+ time,*re-ue!"y+
. amou!t
Interventions are correctly
identi'ed as (/) Independent or (C)
collaborative
1 - 2 interventions are not
identi'ed as (/) Independent or (C)
collaborative or one intervention is
incorrectly labeled
>2 interventions are not identi'ed
as (/) Independent or (C)
collaborative or >1 interventions is
incorrectly labeled
4ationale indenti'ed "or each
intervention is paraphrased and
includes source and correct page
number
1 - 2 rationales are not indenti'ed
"or each intervention or not
paraphrased or incorrect source
and page number given
>2 rationales are not indenti'ed "or
each intervention a!d,or
rationales are not paraphrased
a!d,or incorrect source and page
number given
2014 Lamar State College Port Arthur Page 1
Appropriate evaluations are
included "or short term and long
term goals
Inappropriate or incomplete
evaluations "or 1-2 short term or
long term goals is present
Inappropriate or incomplete
evaluations "or >2 short term or
long term goals is present
Late Pe!alty0
25 points up to 21 hours
/reater than 21 hours may result in
a )ero "or the assignment
Comme!t#0 1otal Poi!t# (ar!ed 2ma3imum
o* ''4
Spelli!g a!d Grammar (rror#
5edu"tio! 2ma3imum o* 6
poi!t#4
Late Poi!t# 5edu"tio!
7ailure to #ubmit ele"tro!i"ally
a# a! atta"hme!t i! proper
*ormat 2MS 89"e )ord4 with
gradi!g rubri" a# :r#t page o*
do"ume!t
Poi!t# dedu"tio! 2ma3imum o*
' poi!t#4
7i!al S"ore
2014 Lamar State College Port Arthur Page 2
Problem List
List and prioritize a minimum of 3 problems.
Problem List ma in!lude onl one "is# for $A$%A statement.
&pe our ans'ers in the spa!e pro(ided. &he bo)es 'ill e)pand as ou tpe.
Problem * %ate $ursing %iagnosis "+& ,tiolog A,- Sub.e!ti(e+/b.e!ti(e %ata







2014 Lamar State College Port Arthur Page 3
Diagnosis by Nanda
&pe our ans'ers in the spa!e pro(ided. &he bo)es 'ill e)pand as ou tpe.
2014 Lamar State College Port Arthur Page 4
DIAGNOSIS BY
NANDA
PLAN/GOAL INT!"NTION
#Indicate I or $%
!ATIONAL
#Para&'rase
in(ormation and
Include !e(erence
Page )%
"AL*ATION
NANDA )+:

S0/"& &,"1
2/AL *1
Patient 'ill

1. 1. 1.
S0/"& &,"1
2/AL *2
Patient 'ill
2. 2. 2.
AB
S0/"& &,"1
2/AL *3
Patient 'ill
3. 3. 3.
Sub.e!ti(e %ata3

S0/"& &,"1
2/AL *4
Patient 'ill
4. 4. 4.
/b.e!ti(e %ata3

L/$2 &,"1
2/AL*1
Patient 'ill
4. 4. 4.
!e(erences #APA ,ormat%:

"e(ie'ed 5 "e(ised 6+27+2014


2014 Lamar State College Port Arthur Page 4

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