Revised Case Study Rubric Fundamental

Criteria What data from the histories are relevant and must be interpreted as clinically significant by the nurse? What VS data are relevant and must be interpreted as clinically significant by the nurse? What assessment data are relevant and must be interpreted as clinically significant by the nurse? What diagnostic and lab results are relevant that must be recognized as clinically significant to the nurse? Lab planning: Creating a plan of care with priority labs Pharmacology Pathophysiology: What is the primary problem/problems? What is the underlying pathophysiology of the primary problem/problems? Levels of Achievement Novice 2 points Less than half the data are present, the main priorities are not present, not interpreted correctly Competent 4 points Some data are missing, but the most relevant data are present and interpreted correctly Proficient 5 points At least 90% of the data are present and interpreted correctly 2 points Less than half of the relevant VS and pain scale are correctly interpreted 4 points Most of the relevant VS and pain scale are listed and interpreted correctly 5 points All relevant VS and pain scale are listed and most are interpreted correctly 2 points Not all of the relevant assessment data are listed and not all the data are correctly interpreted 2 points Lists most abnormals, but does not attempt to interpret them. 4 points Not all of the relevant assessment data are listed, but what are listed are correctly interpreted 4 points Only lists and interprets abnormal labs and diagnostic results 5 points Most of the relevant assessment data are listed and correctly interpreted 0 points Priority lab plan of care is incomplete and not thorough 0 points Pharmacology chart is not complete and not thorough 0 points Problem/problems and patho are incorrect and/or not thorough 4 points Priority lab plan of care is mostly complete and somewhat thorough 4 points Pharmacology chart is mostly complete and somewhat thorough 4 points Identifies the problem/problems and but patho is not thorough 5 points Priority lab plan of care is complete and thorough 5 points Pharmacology chart is complete and thorough 5 points Able to interpret some normal labs & diagnostics and all abnormals 5 points Correctly identifies the problem/problems and pathophysiology thoroughly Developing Nurse Thinking by identifying clinical relationships. What is the relationship of the past medical history and current medications? Is there a relationship between any disease in PMH & the current problem? What is the relationship between the primary care provider’s orders and primary problem? Developing Nurse Thinking by identifying clinical nursing priorities. Which orders do you implement first and why? What nursing priorities will guide your plan of care? What intervention will you initiate based on this priority? What are the priority psychosocial needs and how will the nurse address those needs? Discharge planning Caring and the Art of Nursing 0 points Does not identify relationships 4 points Identifies and describes most relationships correctly 5 points Correctly identifies and describes relationships 5 points Includes minimal aspects of the nursing plan of care. Interpretation is not thorough 8 points Includes most aspects of the nursing plan of care, interpretation is thorough 10 points Includes all aspects of nursing plan of care and interpretation of the nursing plan of care is thorough 0 points Incorrectly identifies the relevant data, incorrectly interprets the data 0 points Discharge plan does not apply to this patient and or is not complete or thorough 0 points Unable to identify or describe the significance of the caring aspects of the art of nursing 4 points Identifies some of the relevant data, correctly interprets the data 4 points Discharge plan is complete, but not thorough 5 points Able to identify 90% of the relevant data, correctly interprets the data 5 points Provides a thorough discharge plan unique to this patient 4 points Identifies and describes the significance of half of the caring aspects of the art of nursing 5 points Identifies and describes the significance many of the caring aspects of the art of nursing Use reflection to develop clinical judgment Effort Total 0 points Does not reflect on clinical judgement 4 points Minimal reflection noted 5 points Minimal effort noted. Case study is poorly completed 25 points Evidence of some effort. Case study is complete but not thoroughly 81 18 5 points Completes the reflection honestly, sincerely, and thoroughly 30 points Evidence of significant effort. Case study is complete and thorough. 100