What subjective or Objective data was present with this type of patient?

Process paper

Rubrics for Process Paper

Write in a Word Document, using APA format (Adapted for T5/2020)

Case presentation (10 points)

• Medical Diagnosis- (Pathophysiology of medical diagnosis including definition, signs &symptoms, and treatment/diagnostic measures) cite your sources. Explain why this topic is important to you. (8)
• Past medical history, Chief Complaints/Date, Relevant Labs Reports and Relevant Data (2)
Nursing Process

Assessment-(10 points)

• What subjective or Objective data was present with this type of patient?(2)
• What did you glean from the chart? (2)
• What information from report was most useful? (2)
• Was there any aspect of your education that helped with this assessment decision? (3)
• Explain why? (1)

Diagnosis (10 points)
• Develop Nursing diagnoses related to medical diagnoses (include primary physical, psychosocial and education nursing diagnosis). (4)
• Why did you choose them for this patient? (1)
• Did you agree with them? (1)
• Did you speak to the preceptor about adding, deleting, or modifying them?(2)
• How did care planning at Stratford help with this? Explain your response. (2)

Planning-(10 points)

• How would you plan your care for such a patient? (2)
• Do you foresee any difficulties with planning when caring for this patient and what or how would it impact your care process? (4)
Did your plan for this patient change as the day progressed? (2)

Implementing- (10 points)

• What institutional resources played a factor in accomplishing your plan? (2
What are the Nursing Considerations for this medical diagnosis? (Are there particular aspects that should be monitored such as lab values or etc.?)(4)
• What are some tasks that could be delegated if any, for this type of patient? Talk about that decision). (4)

Evaluation-(10 points

• Identify one best practice that could impact your care for this patient’s quality of care or patient’s safety. (4)
• What have you learned from choosing and presenting this medical diagnosis? (1)
• How did your patient do? How did you do? (1)
• Were there any institutional barriers and/or facilitators during your shifts? (4)

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What subjective or Objective data was present with this type of patient

APA

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