Care P :
Newborn Care Plan Grading Rubric
Student Name: ______________________________________________
Description
Points Received/
Total Points Possible
Comments
Diagnosis #1
Diagnosis #2
Totals
Patient Information
· Complete patient demographics, pregnancy and delivery information
____/ 2
Medications:
· Identify current meds and purpose
____/ 1
Nursing Diagnosis (Include ALL 3 Dx):
· Reflects the primary diagnosis
· Priorities diagnoses appropriately
· Appropriate for patient scenario
· In acceptable NANDA format
· Includes all parts stem, R/T, AEB
____/ 3
Development of diagnoses
#1
#2
Assessment:
· Appropriate for chosen diagnosis
· Includes objective & subjective historical support diagnosing data
____/3
+ ____/3
= ___/ 6
Patient Outcomes:
· Specific to the patient diagnosis
· Contains the following 4 criteria:
measurable, attainable, realistic, and timed
· All criteria present for patient’s expected outcome
____/3
+ ____/3
= ____/ 6
Intervention/Implementation:
· Includes interventions/ nursing actions directly relating to pt. outcomes
· Specific in action, frequency and contain rationale
· # of interventions is appropriate to help pt./ family meet their outcomes
____/3
+ ___/3
= ____/ 6
Evaluation:
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set
____/3
+ ___/3
= ____/ 6
Total Points
____/ 30
Passing grade = 22.5 / 30 (75%)
** Grading guidelines:
3 = complete and accurate
2 = mostly complete; 1-2 items missing
1= incomplete; some accuracies but significant data missing
0=unsatisfactory/not addressed
** Deductions for late work are at the discretion of the instructor. There may be no more than 10% for every day past the indicated due date.
PatientCare Plan
NUR 4545 Women and Newborn Health Nursing
Student Name:
_____________________________________________
Date of Care:
1
2
/10/2020
Focus of Care Plan: Newborn
Identifying information
: Complete information for newborn AND mother
NEWBORN Initials: C.O Sex: M Birth date: 12/02/2020 Gestational age:
3
9w 5d Birth weight: 3.65 Kg Age (in hours): 192
APGAR scores at birth (1 and 5 min.): 8 (1min) 9 (5mins) Method of feeding: __________ Blood type: O+ Coombs: __________
Transcutaneous Bili (TCB) or Serum Bili (include hour of life): __________ Glucose: __________
MOTHER Initials: A. O Age: 31 Gravida 1 Para (term) 1 (preterm) 0 (abortions/miscarriages) 0 (living children) 1
LMP: ______ Estimated date of delivery (“due date”): _____ Weeks gestation:39 weeks Prenatal Group B Strep: A+
Other abnormal prenatal labs: __________________ Most recent Hemoglobin and hematocrit: __________ Blood Type: __________
EBL: ___________ Episiotomy or laceration (describe by type and/or degree): __________________________________________
Type of anesthesia used during labor and/or birth (if applicable): __________________________________________
FOR ALL CARE PLANS
Type of birth (highlight or bold):
vaginal delivery
Cesarean-section
not delivered/born yet
Is there history of any high-risk situations or complications to previous pregnancy, labor/birth, or postpartum period?
YES
NO
If yes, please list: _______________________________________________________________________________________________________
Is there history of any complications to current pregnancy, labor, birth, postpartum, or newborn?
YES
NO
If yes, please list: _______________________________________________________________________________________________________
Medications ordered for your patient: (add more columns as needed)
|
Medication: |
Drug Category: |
Prescribed for: |
Dose, route, and frequency |
|
Hep. B |
|||
|
Phytonadione (Vitamin K) |
|||
|
Erythromycin 5mg/gram (0.5%) Ophthalmic ointment |
|||
|
Sucrose (Toot sweet, Sweet ease) 24% oral sol 1 drop |
Nursing Diagnoses
List the top three nursing diagnoses for this patient. Use NANDA format (diagnosis, related to, as evidenced by) and place the diagnoses in their priority order. Briefly discuss the rationale for this priority order.
|
Priority |
Nursing Diagnosis |
Related to |
As Evidenced By |
Rationale for Priority Order (Why is 1st diagnosis first, 2nd diagnosis, second, etc.) |
| 1 | ||||
| 2 | ||||
| 3 |
Select the top two nursing diagnoses and complete a work-up table for each. PLEASE NOTE: the two diagnoses must be significantly different from each other to demonstrate maximum learning.
Nursing Diagnosis #1:
(WRITE YOUR COMPLETE DIAGNOSIS HERE)
|
Assessment (Include all assessment data related to diagnosis) |
Patient Outcome (Desired outcome or evaluation parameters, using S-M-A-R-T) |
Nursing Interventions & Rationale (Specific nursing actions with rationale) |
Evaluation (Was each outcome met or unmet? Why?) |
Nursing Diagnosis #2:
(WRITE YOUR COMPLETE DIAGNOSIS HERE)
|
Assessment (Include all assessment data related to diagnosis) |
Nursing Interventions & Rationale (Specific nursing actions with rationale) |
Rev. 8.19