Nursing Care Plan Scoring Rubric
Category
Assessment

Includes subjective, objective &
historical data that support actual or
risk for nursing diagnosis
Diagnosis
 Includes the most appropriate
diagnosis for patient and ordinal
number that includes all appropriate
parts (stem, related to or R/T, and as
evidenced by AEB for actual
diagnosis) and is NANDA approved.
Planning (Goal Setting)
 Includes short-term and long term
goal that is most appropriate for the
patient/family and the nursing
diagnosis. Goal should be
measurable by at least two criteria
and have a target date or time.
Implementation (Interventions

Includes interventions or nursing
actions that directly relate to the
patient's goal and include a
referenced rationale (if applicable).
Provides minimum 3 appropriate
interventions to help patient or family
meet their goal.
Evaluation
 Includes data that is listed as criteria
in goal statement. Based on this
data, goal is determined to be met,
partially met, or not met. If goal was
not met or partially met, plan of care
is revised or continued, and a new
evaluation date/time is set.
10 points (Good)
8 (Fair)
4 (Poor)
2 (Incomplete)
Includes all pertinent data related
to nursing diagnosis and does not
include data that is not related to
nursing diagnosis.
Includes all pertinent data
related to nursing diagnosis,
but also includes data not
related to nursing diagnosis.
Does not include all
pertinent data related to
nursing diagnosis. May also
include data that does not
relate to nursing diagnosis.
Assessment
portion is
incomplete.
Diagnosis is appropriate for
patient and ordinal level, and
diagnosis is NANDA approved.
Diagnosis also includes all parts
and information is listed in correct
part of diagnosis.
Diagnosis is appropriate for
patient and ordinal level, and
diagnosis is NANDA
approved, but does not
include all parts or
information is listed in wrong
part of diagnosis.
Diagnosis is not appropriate
for patient and ordinal level
(first diagnosis, second
diagnosis, etc.). May also
not be NANDA and may not
include all parts.
Diagnosis
portion is
incomplete.
Goal statement is patient or family
oriented and contains two
measurable criteria and a target
date or time.
Goal statement is patient or
family oriented and contains
at least one measurable
criteria or a target date/time.
Goal statement is not
patient or family oriented
and may not have
measurable criteria or a
target date or time.
Goal portion is
incomplete.
Interventions portion contains
adequate number of interventions
to help patient/family meet goal,
and interventions are specific in
action and frequency, and are
listed with referenced rationales.
Provides minimum 3 appropriate
interventions to help patient or
family meet their goal.
Interventions portion contains
adequate number of
interventions to help
patient/family meet goal, but
interventions may not be
specific, labeled or listed with
rationales.
Interventions portion does
not include adequate
number of interventions to
help patient/family meet
goal. Interventions may
also not be specific, labeled
or listed with rationales.
Interventions
portion is
incomplete.
Evaluation portion does contain
data that is listed as criteria in
goal statement. Does describe
goal as met, partially met, or not
met. If goal was partially met or
not met, includes revision and/or
new evaluation date/time.
Evaluation portion does
contain data that is listed as
criteria in goal statement, but
does not describe goal as
met, partially met, or not met.
May also not include revision
or new evaluation date/time.
Evaluation portion does not
contain data that is listed as
criteria in goal statement.
May also not describe goal
as met, partially met, or not
met. May also not include
revision or new evaluation
date/time.
Evaluations
portion is
incomplete.
Total score:______________/ 50 points
Admitting/current medical diagnosis & definition:
Student Name: Jeannie Horta
Hypertensive Emergency: systolic BP greater than 180 mm Hg and/or diastolic BP greater than 120 mm
Hg. BPs often can be greater than 220/140 mm Hg. With evidence of target organ disease.
Acute chronic HF: complex clinical syndrome that develops in response to myocardial insult. It results in
the inability of the heart to provide sufficient blood to meet the oxygen (O2) needs of tissues and organs.
Assessment
Include only the supporting
data cluster related to each
diagnosis
Subjective data:
Pt uncommunicative.
Objective data:
NKDA, BP 190/95, T 36.7
C, HR 69, RR 20 on BIPAP,
SPO2 98%. FiO2 40,
Expired TV 535, Peak
airway 18, min volume 11.7
Cardiac assessment
revealed normal S1 and S2,
EKG monitoring showed
QRS complex block
(Purkinje block), Lungs
clear and equal bilaterally.
Occasional PVCs, ST
depressions. Hx of HTN,
COPD, Asthma, Substance
abuse, CAD. Hgb 11.4, Hct
36.6, glucose 298, BUN 26,
Trop 0.040, 2,984 BNP, Ddimer 1,125. Pulses 3+,
A/Ox2 pt lethargic and hard
to arouse. Not following
commands but is
maintaining airway. Pt
states she doesn’t know
where she is, and not
tracking movement.
Nitroglycerin drip rate of
50mg/mL. Titrate as
needed 2-200 mcg/min. IV
in RT AC clean, dry intact
and flushes.
Diagnosis
Plan
Provide one (1)
PRIORITIZED Nursing
Diagnosis
Provide 1 short- & 1 longterm goal relevant to the
nursing diagnosis
Nursing Dx: Ineffective
myocardial tissue
profusion.
1. Patient will (shortterm goal)
R/T: Purkinje block; 2nd
degree heart block.
AEB: Compresses
QRS complex, ST
depression, BNP
2,984, 0.040 troponin.
Use of BIPAP, and
reduced level of
consciousness.
maintain adequate
cardiac output as
evidenced by strong
peripheral pulses, systolic
BP within 20 mm Hg of
baseline, HR 60 to 100
beats/min with regular
rhythm, urinary output
30 mL/hr or greater,
warm, and dry skin, and
normal level of
consciousness.
Date(s): 3-5-22
Instructor: Ms. Raley and Ms. Rosado
Implementation
Provide 3 appropriate interventions w/ rationales for short-term goal
and 3 appropriate interventions w/ rationales for long-term goal.
1a. Nurse will keep ECG monitor alarms on at all times.
Rational: Alarm signals alert the nurse to potential lifethreatening dysrhythmias or pacemaker malfunction.
Disabling or turning off alarms places the patient at higher
risk. Appropriate attention to this alarm reduces the risk of
harm to the patient.
(Gulanick, 2019)
Evaluation
Evaluate outcomes &
evaluative criteria for both
short- & long-term goal.
1. Outcome (shortterm goal)
Pt goal not met. Pt
BP remained above
150, and pt was
minimally responsive
to treatments.
1b. Nurse will administer Vasodilators as prescribed.
Rational: Vasodilators reduce preload, which decreases
pulmonary congestion, and reduce afterload, which
enhances the pumping ability of the ventricle. (Gulanick,
2019)
1c. Nurse will assess for the signs of reduced cardiac
output: rapid, slow, or weak peripheral pulses;
hypotension; dizziness; syncope; shortness of breath;
chest pain; fatigue; and restlessness.
Rational: The patient's tolerance of a dysrhythmia and the
need for specific treatment is based on clinical
manifestations of decreased cardiac output.
(Gulanick, 2019)
Nursing care plan p.2
Student:
Assessment
Include only the supporting
data cluster related to each
diagnosis
Date:
Diagnosis
Provide one (1)
PRIORITIZED Nursing
Diagnosis
Instructor:
Plan
Provide 1 short- & 1 longterm goal relevant to the
nursing diagnosis
2. Patient will (longterm goal)
maintains optimal
tissue perfusion to
vital organs, as
evidenced by warm
and dry skin, present
and strong peripheral
pulses, vitals within
patient’s normal
range, balanced I&O,
absence edema,
normal ABGs, alert
LOC, and absence of
chest pain by
discharge.
Implementation
Evaluation
Provide 3 appropriate interventions w/ rationales for short-term goal
and 3 appropriate interventions w/ rationales for long-term goal.
Evaluate outcomes &
evaluative criteria for both
short- & long-term goal.
2a. Nurse will Assess for the signs of reduced
cardiac output: rapid, slow, or weak peripheral
pulses; hypotension; dizziness; syncope; shortness
of breath; chest pain; fatigue; and restlessness.
Rational: The patient's tolerance of a dysrhythmia
and the need for specific treatment is based on
clinical manifestations of decreased cardiac output.
(Gulanick, 2019)
2. Outcome (longterm goal)
Pt goal not met.
Unable to reassess
due to pt being in
diagnostic procedure
when leaving the
floor.
2b. Nurse will monitor for side effects of the
medication therapy.
Rational: Medications prescribed to treat
dysrhythmias can themselves be capable of
causing more dysrhythmias.
(Gulanick, 2019)
2c. Nurse will Instruct the patient regarding the
treatment versus maintenance medications: dose,
method of administration.
Rational: Patients in the acute setting may need
an explanation as to the variety of medications
that may be required to successfully treat the
problem. Patients with chronic conditions may
require long-term self-management.
(Gulanick, 2019)
Citation: Kwong, M.H.D.R.C.R.D.H. J. ([2021]). Lewis's Medical-Surgical Nursing (11th Edition). Elsevier Health Sciences
(US). https://bookshelf.vitalsource.com/books/9780323551496
Gulanick, M., PhD, APRN, Myers, F.A.J. L., RN, & MSN ([2019]). Nursing Care Plans: Diagnoses, Interventions, and Outcomes (9th Edition).
Elsevier Health Sciences (US). https://bookshelf.vitalsource.com/books/9780323428187
Nursing care plan p.3