OB Care Plan Essay. Course: NURS 316L NURSING CARE PLAN RUBRIC NAME: COURSE: PATIENT INITIALS: Criteria History of Present Illness Physical Assessment, & Diagnostic tests/ procedures Past Medical & Surgical History, Pathophysiology Erikson’s Developmental Stages Socioeconomic/ Psychosocial Page 1 of 3 DATE: PATIENT DISEASE/DISORDER: Exceeds Expectations Meets Expectations Approaching Expectations HPI explained in detail with accurate and indepth understanding of chief complaint and supported by evidence based citations Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and supported by evidence based citations Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations. Describes socioeconomic and cultural background in HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations Past medical/surgical; history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations Describes socioeconomic and cultural background in HPI explained in limited detail with marginal understanding of chief complaint and no support from evidence based citations Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations Describes socioeconomic and cultural background in Does Not Meet Expectations HPI details limited with poor understanding of chief complaint and no evidence based citations to support Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations No past medical/surgical history given without explanation; no preexisting medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations Describes socioeconomic and cultural background Course: NURS 316L NURSING CARE PLAN RUBRIC Criteria Exceeds Expectations Meets Expectations Approaching Expectations complete detail with references Identifies 3 psychosocial concerns Lists 3 or more appropriate collaborative issues/concerns Rationale demonstrates excellent understanding of consults and interventions some detail with references Identifies 2 psychosocial concerns Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory understanding of consults and interventions vague detail without references Identifies 1 psychosocial concern. OB Care Plan

OB Care Plan Essay. Lists 1 appropriate collaborative issue/concern Rationale demonstrates vague understanding of consults and interventions Potential Health Deviations Identifies TWO prioritized risk factors in proper format Writes 3 independent nursing interventions Identifies 1 prioritized risk factor in proper format Writes 2 independent nursing interventions Priority Nursing Diagnosis TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis Planning/Goals & Evaluation Goal is measureable, realistic, related to the problem; Data supports if goal is met, not met with appropriate revisions Identifies 4 independent One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis Goal is not measureable, realistic, related to the problem; Data somewhat supports if goal is met, not met with appropriate revisions Identifies 3 independent Identifies 2 prioritized risk factors but not in proper format Writes 1 independent pertinent nursing intervention Written incorrectly with sufficient data to support diagnosis, not a priority Assessment Interprofessional Consults & Discharge Referrals Implementation and Page 2 of 3 Goal is not measureable, not realistic, related to the problem; Data vaguely supports if goal is met, not met with inappropriate revisions Identifies 2 independent Does Not Meet Expectations with no detail without references Identifies no psychosocial concerns Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory understanding of consults and interventions Does not identify prioritized risk factors Writes 0-1 independent nursing intervention not pertinent to the diagnosis Written incorrectly, not in correct format, or without sufficient data to support diagnosis Goal is not measureable, not realistic, not related to the problem; Data does not support if goal is met, not met with inappropriate revisions Identifies 1 independent Course: NURS 316L NURSING CARE PLAN RUBRIC Criteria Exceeds Expectations Rationale interventions with teaching; Each is supported with scientific rationale using textbook or evidence based citations Medications Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug Accurate APA format, Appropriate citations & references, No spelling or grammar errors General Organization Meets Expectations interventions with teaching; Scientific rationale is supported with scientific rationale using textbook or evidence based citations Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug 1-2 APA format errors, Some citations, references are appropriate, Minimal spelling or grammar errors Approaching Expectations interventions with teaching; Scientific rationale is vaguely relevant & not supported from textbook Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug Many APA format errors, Inappropriate citations or references, Many spelling or grammar errors. OB Care Plan

OB Care Plan Essay. COMMENTS: FACULTY SIGNATURE: Page 3 of 3 DATE: Does Not Meet Expectations interventions with teaching; Scientific rationale is not relevant & not supported from textbook Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient No APA formatting, No citations or references included, Many spelling or grammar errors NURSING CARE PLAN Student Instructor Date Course Unit/ Room# Patient Initial Code Status Allergies Temp (C/F Site) Height/Weight Final EDC/Current Gestational Age: Pulse (Site) Respiration History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with evidence based citations Chief Complaint (if possible, use patients words): HPI (PQRST of chief complaint, along with other pertinent pregnant complications [if any]): ___ y.o. at ___ week’s gestation, arrives to the hospital with prior noted chief complaint. Admit Dx: DOB Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10 Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations. If on postpartum, BUBBLE-HE for maternal assessment and if on antepartum/intrapartum, the following apply: fundal height, CV/Thorax, perineum, SVE, and fetal heart rate Category. NURSING CARE PLAN Relevant Diagnostic Procedures/ Results & Pertinent Lab tests/ Values (with normal ranges), include dates and rationales supported with Evidence Based Citations Past Medical and Surgical History, Pathophysiology of Medical Diagnoses (include dates, if not found state so) Supported with Evidence Based Citations Pertinent Labs Current CBC: Medical Hx: GBS: OB Hx: Prenatal Panel: Surgical Hx: PIH panel (if applicable): Family Hx: Relevant Diagnostic Procedures Ultrasound (latest): Erikson’s Developmental Stage (with Rationale). Provide examples of how client meets/doesn’t meet chosen stage (supported by Evidence Based Citations). Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns, (3) to include the following Social Determinants of Health ❋Economic Stability ❋ Education ❋Social and Community Context ❋ Health and Health Care ❋ Neighborhood and Built Environment supported with Evidence Based Citations Socioeconomic Cultural: Spiritual: Three psychosocial concerns, based on above assessments: NURSING CARE PLAN 1. 2. 3. Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each (RISK FOR XXX, AS EVIDENCED BY XXX) Priority Nursing Diagnosis (at least 2) Written in three-part statement *Risk Diagnoses NEVER go in this section. Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing Diagnosis) *Think SMART GOAL* Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale Supported with Evidence Based Citations Prioritized Independent and collaborative nursing interventions; include further assessment, Intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation Goal Met, Partially Met, or Not Met & Explanation NURSING CARE PLAN MEDICATION LIST Medications (with APA citations) Class/ Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient NURSING CARE PLAN Medications (with APA citations) Class/ Purpose Route Frequency Dose (& range) If out of range, why? Mechanism of action Onset of action Common side effects Nursing considerations specific to this patient Updated FII17-NCC References …