Posted: December 21st, 2022
nursing care plan assessment rubrics
The Development of a Rubric to Assess a Nursing Care Plan
Introduction
The nursing care plan is not an event but the result of a process. This process is referred to as the nursing process (Toney-Butler & Thayer, 2019). The process involves five integrated steps that are assessment, a nursing diagnosis out of the assessment, planning for care, implementation of the plan, and finally evaluation of the effectiveness of care (Toney-Butler & Thayer, 2019). It is important that the nursing diagnosis in a nursing care plan be derived from the North American Nursing Diagnosis Association-International (NANDA-I) taxonomy (Herdman & Kamitsuru, 2018).
The Rubric as a Means of Scoring
The rubric is a grid that has allocated points against criteria that the student needs to meet in order to score those points. A rubric can either be holistic (scoring the test paper as a whole), or analytical (scoring the test paper in sections) (Oermann & Gaberson, 2014; McDonald, 2018; Burghart & Panettieri, 2009).
The following is an analytical rubric that assesses the student’s abilities in the formulation of a nursing care plan. It gives a least score of 25% and a maximum score of 100%. The underlying assumption is that a student who has been attending classes cannot logically score a zero.
Table 1: Analytical rubric for a nursing care plan
| Poor
(5 points) |
Average
(10 points) |
Good
(15 points) |
Exceptional
(20 points)
|
|
| Assessment
Assembly of critically assessed data on the patient. This data is both subjective (verbal description from the patient) and objective (measured by the nurse) |
Does not provide essential patient data needed for correct nursing diagnosis.
Includes some unnecessary data not useful for the nursing diagnosis. Data not obtained either objectively or subjectively. Does not indicate current pertinent diagnostic data like laboratory values or even attempt to interpret them. Does not give a summary of the pathophysiology of the patient’s health problem. Does not appropriately cite references in correct APA format. Does not list the current medications the patient is on or the rationale behind any of them. Does not provide a genogram. |
Provides all essential patient data needed for correct nursing diagnosis. Includes some unnecessary data not useful for the nursing diagnosis.
Data obtained both objectively and subjectively. Indicates current pertinent diagnostic data like laboratory values and interprets them. Includes some diagnostic data not useful in the nursing diagnosis. Presents a summary of the pathophysiology of the patient’s health problem but does not appropriately cite references in the correct APA format. Lists the current medications the patient is on with no rationale behind each of them. Does not attempt to provide a genogram. |
Provides all essential patient data needed for correct nursing diagnosis (including allergies).
Includes some unnecessary data not useful for the nursing diagnosis. Data obtained both objectively and subjectively. Indicates current pertinent diagnostic data like laboratory values and interprets them. Also includes some diagnostic data not useful in the nursing diagnosis. Presents a summary of the pathophysiology of the patient’s health problem & appropriately cites references in the correct APA format. Lists the current medications the patient is on and the rationale behind each of them. May provide a genogram or not. |
Provides all essential patient data needed for correct nursing diagnosis (including allergies).
Data obtained by assessment of all body systems (objective), history (subjective), and measurements like temperature (objective). Indicates current pertinent diagnostic data like laboratory values and interprets them. Presents a succinct summary of the pathophysiology of the patient’s health problem and appropriately cites references in the correct APA format. May provide a genogram showing family line of a particular condition. Lists all the current medications the patient is on and the rationale behind each of them. |
| Nursing Diagnosis
Arrival at a NANDA nursing diagnosis extrapolated from the subjective and objective data obtained during assessment |
Provides a nursing diagnosis that is definitely not NANDA-approved and that does not correctly reflect the patient’s situation.
Does not mention nursing theorist influencing care plan. |
Provides a nursing diagnosis that may not be NANDA-originated and that may also not correctly reflect the patient’s objective and subjective data.
Does not mention nursing theorist influencing care plan. |
Provides an acceptable data-backed NANDA nursing diagnosis that correctly reflects the patient’s objective and subjective data.
Does not mention nursing theorist influencing care plan (e.g. Virginia Henderson and the Need Theory). |
Provides a feasible and data-backed NANDA nursing diagnosis that correctly reflects the patient’s objective and subjective data.
Mentions nursing theorist influencing care plan (e.g. Virginia Henderson and the Need Theory). |
| Planning (Care Plan)
The laying down of desired goals to be achieved after implementation of the nursing plan of care |
Does not provide a proper statement of expected outcome or goal.
There is no target date or time of achievement of goals. Outcomes/ goals not clearly designated as either short-term or long-term. The outcomes are not patient-focussed, or related to the nursing diagnosis, and do not contain any measurable criterion. Does not fill out all the details of a nursing care plan in the required format.
|
Provides some statement of expected outcome but that is not specific, measurable, attainable, or realistic.
No target date or time of achievement of goals. Outcomes/ goals not clearly designated as either short-term or long-term. The outcomes are not patient-focussed, or related to the nursing diagnosis, and do not contain any measurable criterion. Fills out some details of a nursing care plan in the required format. |
Provides a clear statement of expected outcome that is specific, measurable, attainable, realistic, and with a target date or time of achievement.
Outcomes/ goals not clearly designated as short-term or long-term. The outcomes are patient-focussed, are related to the nursing diagnosis, and contain only one measurable criterion. Fills out all the details of a nursing care plan in the required format. |
Provides a clear statement of expected outcome that is specific, measurable, attainable, realistic, and with a target date or time of achievement.
Outcomes/ goals clearly designated as short-term or long-term. The outcomes are patient-focussed, are related to the nursing diagnosis, and contain a minimum of two measurable criteria. Fills out all the details of a nursing care plan in the required format. |
| Intervention
The carrying out of the evidence-based nursing interventions laid out in the nursing care plan |
Nursing intervention not clear.
Interventions do not include any rationales. Interventions are not geared at helping patient and their family regain normalcy and cope. Interventions are not socially, culturally, and religiously sensitive to the patient’s background. Interventions are not related to set patient goals. |
Nursing intervention not clear on which team member is doing what.
Interventions do not all include clear rationales. Interventions are partially geared at helping patient and their family regain normalcy and cope. Interventions are not socially, culturally, and religiously sensitive to the patient’s background. Interventions are not related to set patient goals. |
Develops and implements nursing interventions but that are not clear on which team member is doing what.
Interventions do not all include clear rationales. Interventions are geared at helping patient and their family regain normalcy and cope. Interventions are socially, culturally, and religiously sensitive to the patient’s background. Interventions are related to set patient goals. |
Develops and implements nursing interventions that are clear on which team member is doing what.
Interventions include clear rationales. Interventions are geared at helping patient and their family regain normalcy and cope. Interventions are socially, culturally, and religiously sensitive to the patient’s background. Interventions are related to set patient goals. |
| Evaluation
The objective evaluation of patient data to find out if the outcomes set at the beginning have been met on time or not. |
No data that was set out as measurement criteria for goal achievement.
Does not indicate whether the desired outcomes have been achieved or not. Does not state any teaching given to the patient or the outcome, but may show a discharge plan. Does not give a reworked plan in the event that goals have not been achieved. |
No data that was set out as measurement criteria for goal achievement.
Does not clearly indicate whether the desired outcomes have been achieved or not. Does not state any teaching given to the patient and the outcome, but may show a discharge plan. Does not include revised plan in the event that goals have not been achieved. |
Indicates clearly data that was set out as measurement criteria for goal achievement.
Does not clearly indicate whether the desired outcomes have been achieved or not. States any teaching given to the patient, the outcome, and/ or discharge plan. Does not include revised plan in the event that goals have not been achieved. |
Indicates clearly data that was set out as measurement criteria for goal achievement.
Clearly indicates whether the desired outcomes have been achieved or not. Clearly states any teaching given to the patient, the outcome, and/ or discharge plan. Includes revised plan in the event that goals have not been achieved. |
References
Burghart, G. & Panettieri, R. (2009). Teaching techniques: Faculty guide to rubrics. Radiologic Technology, 80(3), 266-268.
Evaluation Rubrics (n.d.). Retrieved 21 June 2019 from https://cnhs.fiu.edu/_assets/docs/resources/careplanrubric.pdf
Herdman, T.H. & Kamitsuru, S. (Eds) (2018). Nursing diagnoses, definitions, and classifications: 2018-2020, 11th ed. New York, NY: NANDA International.
McDonald, M.E. (2018). The nurse educator’s guide to assessing learning outcomes, 4th ed Burlington, MA: Jones & Bartlett Learning.
Nursing Care Plan Criteria (n.d.). Retrieved 21 June 2019 from https://scf.instructure.com/courses/9653/files/933624/download
Oermann, M.H. & Gaberson, K.B. (2014). Evaluation and testing in nursing education, 4th ed. New York, NY: Springer Publishing Company.
Reason Systems, Inc. (2019). Nursing care plan rubric: A rubric that provides an objective basis for creating and grading care plans. Score from 0-100%. Retrieved 21 June 2019 from https://www.rcampus.com/rubricshowc.cfm?sp=yes&code=H5788W&
Toney-Butler, T.J. & Thayer, J.M. (January 19 2019). Nursing process. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/
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