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

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)

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