Nutritional Care Plan-rubric

N310

January 2011-DRAFT

Category / Exceeds standards / Meets standard / Nearly meets standard / Does not meet standard / No evidence (0 Pts) / Score
Title Page / APA format
6 / Any title page
5 / No title page
Patient education / States what nutrition topics the client needs to learn or review to improve their health for problems 1,2 and high risk problem, cited
6 / States what nutrition topics the client needs to learn or review to improve their health for problems 1 and 2
5 / States at least 1 nutrition topic that their client needs more knowledge about to improve health 4 / Writes something in this box that does not relate to the identified problems 1,2, or high risk; may have just a generic nutrition topic that would be good for anyone to know 3 / Nothing written
Pathophysiology / For all problems including high risk, the pathophysiology is described in detail and cited
6 / For at least one health problem the pathophysiology is described in detail
5 / For the general health status of the client, some physiology is outlined in relation to current symptoms 4 / Medical terms are simply defined and physiology is not related to how the client presents. 3 / Nothing written
Developmental Stage / States one stage of Erickson and describes it, then shows how the client meets or does not meet this stage , citation
6 / States one stage of Erickson that fits the client, describes it, cited
5 / States one stage of Erickson and how the client meets or does not meet it 4 / States one stage of Erickson with no other descriptions 3 / Nothing written
Diagnostic tests / Writes known tests that were done in the recent past and/or tests that should be done (recommended) states why the tests are relevant, cited
6 / Writes tests that should be done or were done and states why they are relevant, cited
5 / Writes what test should be done and why they are relevant
4 / Writes what tests should be done or what tests were done 3 / Nothing written

Numbers= possible points

Total possible=100

Category / Exceeds standards / Meets standard / Nearly meets standard / Does not meet standard / No evidence (0 Pts) / Score
Medical Management / Writes what current medications and or supplements or herbal preparations that the client is currently on, brief description of what each does, AND student lists what medication, supplements, herbal preparations that might be helpful to the client; cite
6 / Lists what current medications the client is on or medications that the client might benefit from; OR could focus only on vitamins, supplements, or herbals that might be helpful; cite
5 / As in meet standards but no cite
4 / Writes something relevant but not a list of medications or vitamins, supplements, herbals etc.
3 / Nothing written
Chief complaint / Writes in “” client’s own words health complaints (more than one) that relates to eating, sleeping, exercising, or stress management; relates to problem 1, 2, and/or high risk problem
6 / Writes in “” client’s own words health complaint relating only to eating or exercising
5 / Writes a health complaint
4 / States client is perfectly healthy and does not identify at least a high risk problem that can be prevented
3 / Nothing written
Medical diagnosis / Writes a pertinent medical diagnosis, non-NANDA, that client has been diagnosed with e.g. PMS, Hypothyroid, DMI or DM2 etc. as evidenced by ______; If client has no medical diagnosis student writes “healthy as evidenced by___”
6 / Writes pertinent diagnosis or healthy with no evidence statement
5 / Writes a NANDA diagnosis with an evidence statement
4 / Writes a NANDA diagnosis
3 / Nothing written
Category / Exceeds standards / Meets standard / Nearly meets standard / Does not meet standard / No evidence (0 Pts) / Score
Review of Systems / Writes an item in each space designated e.g.GI, GU etc. that is pertinent, can be a diagnosis, a symptom or a sign; can also describe a condition e.g. fatigue upon awakening; in spaces where patient is healthy should write something such as “no complaints” or WNL
9 / Writes an item in each space designated e.g.GI, GU etc. that is pertinent, can be a diagnosis, a symptom or a sign; can also describe a condition e.g. fatigue upon awakening; in spaces where patient is healthy student leaves it blank; REQUIRED ITEMS: NEURO MUSCULAR= exercise; NEURO=sleep; GI=eating; PSYCHOSOCIAL=stress management
8 / Might leave some blank that are not pertinent but also leaves out a pertinent system that should have been filled in, e,g. client is on birth control pills and “endocrine” is left blank
7 / Writes something vague in the boxes and does at least write 1 important item in one of the boxes that relates to eating, sleeping, exercising or stress management
5 / Nothing written
Vital signs / Full set of vital signs and blood pressure
4 / Blood pressure and heart rate only
3 / TPR no blood pressure
2 / Nothing written
Patient / Demographics: age, sex, occupation, cultural/ethnic background
4 / Age, sex, cultural/ethnic background
3 / Age, sex
2 / Nothing written
Category / Exceeds standards / Meets standard / Nearly meets standard / Does not meet standard / No evidence (0 Pts) / Score
Problem 1 / Full NANDA diagnosis e.g.
Nutrition: altered, more than body requirements
Related to (or as evidenced by) ______
Problem should relate to eating, exercising, sleeping or stress management.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited 13 / Problem statement not using NANDA terms but pertinent and has “related to” or “as evidenced by” statement.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited
12 / Problem statement or NANDA statement without the related to/as evidenced by. Outcome: Short term and/or long term, measurable
Intervention: should be pertinent
Evaluation: state how you would know the outcome is successful
10 / Problem does not relate to eating, sleeping, exercising, or stress management;
OR problem is listed correctly but is not shown in ROS, or history, or any other place on the map; OR a priority problem (Maslow) is not addressed at all.
Outcome: Short term and/or long term, not-measurable
Intervention: not pertinent or unrealistic
Evaluation: states met or not met with no explanation
7 / Nothing written
Problem 2 / Full NANDA diagnosis e.g.
Nutrition: altered, more than body requirements
Related to (or as evidenced by) ______
Problem should relate to eating, exercising, sleeping or stress management.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited 13 / Problem statement not using NANDA terms but pertinent and has “related to” or “as evidenced by” statement.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited
12 / Problem statement or NANDA statement without the related to/as evidenced by. Outcome: Short term and/or long term, measurable
Intervention: should be pertinent
Evaluation: state how you would know the outcome is successful
10 / Problem does not relate to eating, sleeping, exercising, or stress management;
OR problem is listed correctly but is not shown in ROS, or history, or any other place on the map; OR a priority problem (Maslow) is not addressed at all.
Outcome: Short term and/or long term, not-measurable
Intervention: not pertinent or unrealistic
Evaluation: states met or not met with no explanation
7 / Nothing written
Category / Exceeds standards / Meets standard / Nearly meets standard / Does not meet standard / No evidence (0 Pts) / Score
High Risk / Full NANDA diagnosis e.g.
High risk for Nutrition: altered, more than body requirements
Related to (or as evidenced by) ______
Problem should relate to eating, exercising, sleeping or stress management.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited
9 / Problem statement not using NANDA terms but pertinent and has “related to” or “as evidenced by” statement.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent and cited
Evaluation: state how you would know the outcome is successful, cited
8 / Problem statement or NANDA statement without the related to/as evidenced by.
Outcome: Short term and/or long term, measurable
Intervention: should be pertinent
Evaluation: state how you would know the outcome is successful
7 / Problem does not relate to eating, sleeping, exercising, or stress management;
OR problem is listed correctly but is not shown in ROS, or history, or any other place on the map; OR a priority problem (Maslow) is not addressed at all.
Outcome: Short term and/or long term, not-measurable
Intervention: not pertinent or unrealistic
Evaluation: states met or not met with no explanation
5 / Nothing written

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