Develop a complete laboratory and diagnostic work-up sheet
Patient Analysis Paper Criteria
Select a client you are caring for in the clinical area with multiple medical and
nursing problems. Write a detailed analysis of the client’s health care problems
using the outline presented below. The data must be obtained from the patient,
his/her chart, significant others, and hospital staff involved in his/her care.
This document must be typed using APA format.
1. The paper must have a good introduction with statement of the patient’s problem.
2. Health history: The health history involves two sections- health history and physical assessment. For easy reading, you need to separate the two sections with the appropriate headings and sub headings. Use the Functional Health Pattern Format for obtaining the patient information. A detailed guideline is found in Lewis, et al., text: Table 3-2 “Nursing History: Functional Health Pattern Format.”
3. Physical Assessment must be completed and written in narrative format and utilize table 3-4.
4. A detailed pathophysiology of the major health problems as they affect the patient’s condition must be included utilizing a pathophysiology tree format or a concept map. (Use a pathophysiology textbook in addition to other nursing textbooks and journals).
5. Develop a complete laboratory and diagnostic work-up sheet. Discuss the rationales for and results of each test and what the abnormal findings indicate for the patient.
6. Using the forms in your clinical package complete the medication worksheets for each medication order for the patient.
7. List all the nursing diagnoses the patient has. The list must be exhaustive and proritized.
8. Develop three priority-nursing diagnoses with a complete plan of care using the forms provided in the clinical package and one psychosocial care plan..
9. Assess teaching needs for your patient, and address one need taking the patient’s cultural background into consideration. Develop a teaching plan for the patient.
10. You must use the APA format for this paper. Cite at least four professional references with one to be research based, one pathophysiology reference, and related to standards of care. Use appropriate grammar, spelling and punctuation.
11. The paper must have a conclusion.
Points-to-Grade Conversion
The points you earn on this activity will be converted to a percentage grade according to the chart below and will be used to determine your grade.
1 Point |
02.22 |
F |
23 Points |
50.60 |
F |
2 Points |
04.44 |
F |
24 Points |
53.28 |
F |
3Points |
06.66 |
F |
25 Points |
55.50 |
F |
4 Points |
08.88 |
F |
26 Points |
57.72 |
F |
5 Points |
11.10 |
F |
27 Points |
59.94 |
F |
6 Points |
13.20 |
F |
28 Points |
62.16 |
F |
7 Points |
15.40 |
F |
29 Points |
64.38 |
F |
8 Points |
17.60 |
F |
30 Points |
66.60 |
D |
9 Points |
19.80 |
F |
31 Points |
68.82 |
D |
10 Points |
22.00 |
F |
32 Points |
71.04 |
D |
11 Points |
24.20 |
F |
33 Points |
72.60 |
D |
12 Points |
26.40 |
F |
34 Points |
74.80 |
C |
13 Points |
28.60 |
F |
35 Points |
77.70 |
C |
14 Points |
30.80 |
F |
36 Points |
79.20 |
C |
15 Points |
33.00 |
F |
37 Points |
81.40 |
B |
16 Points |
35.20 |
F |
38 Points |
84.36 |
B |
17 Points |
37.40 |
F |
39 Points |
86.58 |
B |
18 Points |
39.60 |
F |
40 Points |
88.80 |
B |
19 Points |
41.80 |
F |
41 Points |
90.20 |
A |
20 Points |
44.00 |
F |
42 Points |
93.24 |
A |
21 Points |
46.20 |
F |
43 Points |
95.46 |
A |
22 Points |
48.40 |
F |
44 Points |
97.68 |
A |
******** |
**** |
* |
45 Points |
100 |
A |
Patient Analysis Grading Rubric Page 1
| Criteria | Possible Points | Excellent
3 |
Good
2 |
Average
1 |
Unsatisfactory
0 |
Points Received |
| Introduction | 3 | Introduces the paper as well as states client’s problem | Introduces the paper but not the client | Introduces the client but not the paper | No Introduction | |
| Health History | 3 | Describes the functional health patterns Utilizing all 14 components | Describes the functional Health patterns utilizing 13 of the 14 components | Describes the functional Health patterns utilizing 12 of the 14 components | Describes the functional Health patterns utilizing 11 or less of the 14 components | |
| Physical Assessment | 3 | Describes the comprehensive physical assessment with all 10 components | Describes the comprehensive physical assessment with 9 of the 10 components | Describes the comprehensive physical assessment with 8 of the 10 components | Describes the comprehensive physical assessment with 7 or less of the 10 components | |
| Pathophysiology
Tree/Concept Map |
3 | Logical flow and connects major problems of the client in a tree format/concept map | Logical flow and connects major problems of the client with one omission | Logical flow and connects major problems of the client with one omission | Logical flow and connects major problems of the client with three or more omissions and/or inaccuracy | |
| Laboratory and Diagnostic Data | 3 | Includes and describes abnormal and significant data | Includes and describes abnormal and significant data but fails to describe one data | Includes and describes abnormal and significant data but fails to describe two data | Includes and describes abnormal and significant data but fails to describe three or more data | |
| Medication worksheet | 3 | Comprehensive sheet with all information | Omits one information | Omits two information | Omits three or more information | |
| Nursing Diagnoses | 3 | Exhaustive prioritized list | Not exhaustive but prioritized | Exhaustive but not prioritized | Not exhaustive, not prioritized |
Patient Analysis Grading Rubric Page 2
| Criteria | Possible Points | Excellent
3 |
Good
2 |
Average
1 |
Unsatisfactory
0 |
Points Received |
| Nursing Care Plan: Interentions | 3 | Properly stated with all components, (NANDA format, etiology, and with manifestations) | Properly stated with components with one exception, (NANDA format, etiology, and with manifestations | Properly stated with components with two exceptions, (NANDA format, etiology, and with manifestations | Properly stated with components with three exceptions or more, (NANDA format, etiology, and with manifestations | |
| Nursing Care Plan: Goals | 3 | Properly stated with all components and with evidence | Properly stated with components with one omission and with evidence | Properly stated with components with two omissions and with evidence | Properly stated with components with three or more omissions and with evidence | |
| Nursing Care Plan:
Interventions |
3 | Properly stated with all components (appropriate, action specific, prioritized, and individualized) | Properly stated with all components (appropriate, action specific, prioritized, and individualized) with one omission | Properly stated with all components (appropriate, action specific, prioritized, and individualized) with two omissions | Properly stated with all components (appropriate, action specific, prioritized, and individualized) with three or more omissions | |
| Nursing Care Plan: Rationale | 3 | Properly stated with all components (scientific, individualized, specific and cited) | Properly stated with all components (scientific, individualized, specific and cited)with one omission | Properly stated with all components (scientific, individualized, specific and cited)with two omissions | Properly stated with all components (scientific, individualized, specific and cited)with three or more omissions | |
| Nursing Care Plan: Evaluation | 3 | Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not | Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not, with one omission | Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not,
with two omissions |
Properly stated with all components (Evaluation relates to goal with stated evidence, states goal, outcome(s) stated, and the statement of plan continuance or not, with three or more omissions |
Patient Analysis Grading Rubric Page 3
| Criteria | Possible Points | Excellent
3 |
Good
2 |
Average
1 |
Unsatisfactory
0 |
Points Received |
| Teaching Plan | 3 | Accurate with all components | All components with one error | All components with more two errors | All components with three or more errors | |
| Conclusion | 3 | Thought process clearly stated | Thought process clearly stated with one significant omission | Thought process clearly stated with two significant omissions | Thought process clearly stated with three or more significant omissions | |
| APA and References | 3 | References cited in APA format with four references and/or one or less grammatical error | References cited in APA format with three references and/or two grammatical errors | References cited in APA format with two references and/or three grammatical errors | References are not cited in APA format with no references and/or four or more grammatical errors | |
| Total | 45 | **************** | ************ | ************ | *********** |
Revised April 03, 2017/gc
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