Develop a complete laboratory and diagnostic work-up sheet
Develop a complete laboratory and diagnostic work-up sheet
Patient Analysis Paper Criteria
Select a client you are caring for in the clinical area with multiple medical and
nursing problems. Write a detailed analysis of the client’s health care problems
using the outline presented below. The data must be obtained from the patient,
his/her chart, significant others, and hospital staff involved in his/her care.
This document must be typed using APA format.
1. The paper must have a good introduction with statement of the patient’s problem.
2. Health history: The health history involves two sections- health history and physical assessment. For easy reading, you need to separate the two sections with the appropriate headings and sub headings. Use the Functional Health Pattern Format for obtaining the patient information. A detailed guideline is found in Lewis, et al., text: Table 3-2 “Nursing History: Functional Health Pattern Format.”
3. Physical Assessment must be completed and written in narrative format and utilize table 3-4.
4. A detailed pathophysiology of the major health problems as they affect the patient’s condition must be included utilizing a pathophysiology tree format or a concept map. (Use a pathophysiology textbook in addition to other nursing textbooks and journals).
5. Develop a complete laboratory and diagnostic work-up sheet. Discuss the rationales for and results of each test and what the abnormal findings indicate for the patient.
6. Using the forms in your clinical package complete the medication worksheets for each medication order for the patient.
7. List all the nursing diagnoses the patient has. The list must be exhaustive and proritized.
8. Develop three priority-nursing diagnoses with a complete plan of care using the forms provided in the clinical package and one psychosocial care plan..
9. Assess teaching needs for your patient, and address one need taking the patient’s cultural background into consideration. Develop a teaching plan for the patient.
10. You must use the APA format for this paper. Cite at least four professional references with one to be research based, one pathophysiology reference, and related to standards of care. Use appropriate grammar, spelling and punctuation.
11. The paper must have a conclusion.
Points-to-Grade Conversion
The points you earn on this activity will be converted to a percentage grade according to the chart below and will be used to determine your grade.
1 Point
02.22
F
23 Points
50.60
F
2 Points
04.44
F
24 Points
53.28
F
3Points
06.66
F
25 Points
55.50
F
4 Points
08.88
F
26 Points
57.72
F
5 Points
11.10
F
27 Points
59.94
F
6 Points
13.20
F
28 Points
62.16
F
7 Points
15.40
F
29 Points
64.38
F
8 Points
17.60
F
30 Points
66.60
D
9 Points
19.80
F
31 Points
68.82
D
10 Points
22.00
F
32 Points
71.04
D
11 Points
24.20
F
33 Points
72.60
D
12 Points
26.40
F
34 Points
74.80
C
13 Points
28.60
F
35 Points
77.70
C
14 Points
30.80
F
36 Points
79.20
C
15 Points
33.00
F
37 Points
81.40
B
16 Points
35.20
F
38 Points
84.36
B
17 Points
37.40
F
39 Points
86.58
B
18 Points
39.60
F
40 Points
88.80
B
19 Points
41.80
F
41 Points
90.20
A
20 Points
44.00
F
42 Points
93.24
A
21 Points
46.20
F
43 Points
95.46
A
22 Points
48.40
F
44 Points
97.68
A
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45 Points
100
A
Patient Analysis Grading Rubric Page 1
Criteria
Possible Points
Excellent
3
Good
2
Average
1
Unsatisfactory
0
Points Received
Introduction
3
Introduces the paper as well as states client’s problem
Introduces the paper but not the client
Introduces the client but not the paper
No Introduction
Health History
3
Describes the functional health patterns Utilizing all 14 components
Describes the functional Health patterns utilizing 13 of the 14 components
Describes the functional Health patterns utilizing 12 of the 14 components
Describes the functional Health patterns utilizing 11 or less of the 14 components
Physical Assessment
3
Describes the comprehensive physical assessment with all 10 components
Describes the comprehensive physical assessment with 9 of the 10 components
Describes the comprehensive physical assessment with 8 of the 10 components
Describes the comprehensive physical assessment with 7 or less of the 10 components
Pathophysiology
Tree/Concept Map
3
Logical flow and connects major problems of the client in a tree format/concept map
Logical flow and connects major problems of the client with one omission
Logical flow and connects major problems of the client with one omission
Logical flow and connects major problems of the client with three or more omissions and/or inaccuracy
Laboratory and Diagnostic Data
3
Includes and describes abnormal and significant data
Includes and describes abnormal and significant data but fails to describe one data
Includes and describes abnormal and significant data but fails to describe two data
Includes and describes abnormal and significant data but fails to describe three or more data
Medication worksheet
3
Comprehensive sheet with all information
Omits one information
Omits two information
Omits three or more information
Nursing Diagnoses
3
Exhaustive prioritized list
Not exhaustive but prioritized
Exhaustive but not prioritized
Not exhaustive, not prioritized
Patient Analysis Grading Rubric Page 2
Criteria
Possible Points
Excellent
3
Good
2
Average
1
Unsatisfactory
0
Points Received
Nursing Care Plan: Interentions
3
Properly stated with all components, (NANDA format, etiology, and with manifestations)
Properly stated with components with one exception, (NANDA format, etiology, and with manifestations
Properly stated with components with two exceptions, (NANDA format, etiology, and with manifestations
Properly stated with components with three exceptions or more, (NANDA format, etiology, and with manifestations
Nursing Care Plan: Goals
3
Properly stated with all components and with evidence
Properly stated with components with one omission and with evidence
Properly stated with components with two omissions and with evidence
Properly stated with components with three or more omissions and with evidence
Nursing Care Plan:
Interventions
3
Properly stated with all components (appropriate, action specific, prioritized, and individualized)
Properly stated with all components (appropriate, action specific, prioritized, and individualized) with one omission
Properly stated with all components (appropriate, action specific, prioritized, and individualized) with two omissions
Properly stated with all components (appropriate, action specific, prioritized, and individualized) with three or more omissions
Nursing Care Plan: Rationale
3
Properly stated with all components (scientific, individualized, specific and cited)
Properly stated with all components (scientific, individualized, specific and cited)with one omission
Properly stated with all components (scientific, individualized, specific and cited)with two omissions
Properly stated with all components (scientific, individualized, specific and cited)with three or more omissions
Nursing Care Plan: Evaluation
3
Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not
Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not, with one omission
Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not,
with two omissions
Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not, with three or more omissions
Patient Analysis Grading Rubric Page 3
Criteria
Possible Points
Excellent
3
Good
2
Average
1
Unsatisfactory
0
Points Received
Teaching Plan
3
Accurate with all components
All components with one error
All components with more two errors
All components with three or more errors
Conclusion
3
Thought process clearly stated
Thought process clearly stated with one significant omission
Thought process clearly stated with two significant omissions
Thought process clearly stated with three or more significant omissions
APA and References
3
References cited in APA format with four references and/or one or less grammatical error
References cited in APA format with three references and/or two grammatical errors
References cited in APA format with two references and/or three grammatical errors
References are not cited in APA format with no references and/or four or more grammatical errors
Total
45
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Revised April 03, 2017/gc
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