Name ____________________
Unit _________ Date ______
N450 Nursing Process for Care Maps Grade Sheet
Assessment
10/_________
1. Filled out developmental form completely. Calculations were completed.
2. Obtained a reasonable history from the child and family.
3. Completed weekly teaching and play based on client and family needs.
4. Analysis of needs was accurate and complete.
5. Web based article for nurses or doctors on disease(s) was present and highlighted.
6. Labs were interpreted, medication calculation were done, drug information was completed.
Concept Map
6/_________
1. Met client’s expressed need/concern as #1 problem.
2. Addressed family’s expressed need/concern as #2 problem.
3. Addressed reason why child is in need of nursing care/hospitalized as #3 problem
4. Developed holistic nursing diagnoses based on MRM. It is okay to create your own dx.
5. Clearly prioritized each diagnosis.
6. Included and labeled subjective and objective data for each diagnosis.
7. Drew arrows to show linkages among the diagnostic labels.
8. Put all relevant and existing problems on care map
Client/Family Centered Goals
2/_________
1. Developed goals to match diagnoses that were based on client/family needs.
2. Mutual goals identified were health directed, satisfied needs, and promoted growth.
3. Clearly identified client centered goals rather than nursing goals.
Holistic Nursing Interventions
10/_________
1. Interventions were holistic in nature.
2. Interventions were specific – written like an order so others can follow through.
3. Interventions clearly addressed the need/problem.
4. Interventions were complete and not redundant among diagnoses.
5. All physical care needs including routine care needs (frequent assessment needs,
eating, VS, checking IV rate and site, I & O, etc.) were addressed.
6. Oversight of interdisciplinary care needs (RT, OT, PT, SW, etc.) was addressed.
7. Interventions facilitated rapport, trust, client/family control and affirmed strengths.
8. Interventions were appropriated to the assessed developmental level of the child.
9. Avoided writing interventions as nursing goals (i.e. encourage activity). Instead wrote
very specific intervention (i.e. take child to playroom 3 times).
Evaluation
2/_________
1. Evaluation was complete.
Overall Quality
5/_________
1. Grammar, spelling, sentence structure, legible penmanship, neatness.
2. Submitted on time.
3. Placed in a folder.
4. Forms were placed in the specified order.
5. Student incorporated prior feedback from teacher into this work.
Total 35/_________
Weekly Care Map Requirements
Weekly Clinical Papers
1. Obtain and analyze information from child, family, and nurse’s perspectives.
Remember: The client is the primary source of information, parents/family are
secondary sources, and the chart and other health care providers are a tertiary source
of information.
2. Fill out weekly care plan form. Weekly forms are available on
http://www.harding.edu/dclayton
Note: Teaching and play sessions are to be done each weekly. Both are based on
what client and family say they want to know, to learn, or to do.
3. Develop a plan of care for the time you are there with the client. Be prepared to
articulate plan of care to instructor at the beginning of each clinical day. Data can
continue to be collected and the plan refined during the shift.
a. Plan of care is to be based on:
1) client/family primary need from their perspective.
2) all care related to reason for being hospitalized during your clinical time
3) all routine care during your clinical time
4) care by other health care providers (PT, RT, OT SW etc)
b. Complete medication calculation and medication information sheets.
Be sure to state if drug is within the normal range, too high, or too low.
Contact instructor before time of the medication if dosage is either too high or too
low.
c. Obtain lab information off the computer at Children’s Hospital.
Note: You will have to ask the clerk or RN to do this for you. Ask the RN to get
this for you ahead of time as they need to work it into all their other tasks.
d. Evaluate care given based on the criteria given in syllabus.
4. Turn in all components of the weekly care plan in a flat folder with your name clearly
written in the upper right hand corner. Instructor will specify due date for completed
plans of care.
5. Order for Weekly Clinical Papers in the following order and staple:
a. Cover Sheet - professional looking with your name, the unit, and the week.
b. Weekly Nursing Analysis of Needs (2 pages)
c. Teaching and Play form
d. Care Planning Form (Assessment 4 pages)
e. Your Concept Map (diagram of problems/needs)
f. Care Map Intervention sheets (use as many as are needed to articulate nursing
care needs)
g. Evaluation (1 page)
h. Physical Assessment Sheet
i. Medications Calculation & Drug Info (1 page)
j. Lab Interpretation sheet with printed labs stapled under this page
Be sure to cut off all identifying information including record numbers
k. ACH Flow sheet
l. Student Feedback form – if used
6. Keep all care plans in a flat folder. Clearly mark on the front a number or week of
care plan. Place most recent care plan on top.
7. Students are expected to incorporate the feedback given by instructor into the next
weekly care plan or deductions will be made. If comments are unclear it is your
responsibility to clarify what is expected with the instructor.