Identify and list all nursing diagnoses
1. Students will work individually to present nursing care plan.
2. The Student will select a patient from the clinical setting with a medical/surgical condition.
3. The clinical instructor will approve the patient selected prior to beginning work on the presentation into insure a variety medical conditions/diagnoses are chosen
and to avoid duplication.
4. A list of at least 3 references in the most recent APA format will be provided to the instructor. References must be recent (less than 5 yrs), nursing, and one
research article.
• The care plan must be typed and appropriately formatted.
5. Identify and list all nursing diagnoses (problems that represent the patient’s responses to the medical diagnosis).
• Care plans must include a minimum of one of each of the following nursing diagnoses
o Physiological
o Psychosocial
o Knowledge deficit (teaching need)
Nursing Diagnosis (NANDA) __________________________________________________
Related to (what factors are causing the problem) ______________________________________
As evidenced by (assessment findings- what did you discover that lead you to develop the nursing diagnosis)
____________________________________________________________
6. Develop the plan of care to address TWO of the identified problems with date, goals, outcomes, interventions, rationale, and evaluation criteria.
• Goals are broad
• Outcomes are specific, measurable, realistic and concise steps that the patient must accomplish to achieve the general goal. Outcomes should flow from the
nursing diagnosis. You should aim to alleviate the problems identified in the “As Evidenced By” portion of your nursing diagnosis.
• Interventions should include the rationale for doing them. Rationale must be based on data from the literature and references must be cited.
• Patient education and discharge planning should be included in the interventions.
• Evaluation criteria should state whether the outcomes are met. If outcomes have not been met, how are you going to revise the plan of care?
Stratford University School of Nursing
Nursing Care Plan Rubric
Student Name: _______________________ Date: _________________________
Instructor: ____________________________ Course: _____NSG 240 Clinical_
Objectives Potential Points Points Earned
Brief admission diagnosis and history included. Medical diagnosis defined. 3
Medications and Lab/Diagnostic Results and explanations accurate. 5
Correctly identifies all actual and potential nursing diagnoses and relates to pt history. 5
Correctly states selected nursing diagnoses (physiologic, psychosocial, knowledge deficit) including related to/as manifested by. 9
Establishes realistic goals to support nursing diagnoses. 6
Establishes measurable goal statements. 6
Short term goals support achievement of long term goals. 6
Interventions are clear and concise. 6
Interventions clearly support related goals. 6
Interventions include frequency of action 6
Rationales clearly support inclusion of intervention in care plan. 6
All rationales are supported by reference. 6
Expected outcomes relate to the interventions 6
Evaluation statements are clear and concise per guidelines. 6
Unmet goals include action plan (modifying plan or establishing a new time frame for evaluation). 5
References include at least two course textbooks and one nursing journal article; including APA format. 6
Care plan is typed, free of spelling/syntax/grammatical errors (4).
Care plan template appropriately used (3). 7
Total Score: 100
Final Evaluation: Satisfactory (80%)
If unsatisfactory, correct named deficiencies and resubmit for further evaluation on ____________