Nursing Process Rubric - UNRS 411

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

Identifying Data 1%

Data is complete and accurate

Data is complete and accurate

Required data present

Past Medical/Surgical History/

Chronic Conditions 2%

INCLUDES ABOVE AVERAGE

PLUS: Discussion is comprehensive,
cohesive, and interrelated reflecting
thorough chart review and history
taking

Data is complete and accurate re: past

medical/surgical history and chronic
conditions
Info is obtained from chart review, RN,
MD and patient/family interviews

Required data present

Some limitations in information o

Recent Medical History/ Reason

for Admission/
Course of Hospitalization 2%

INCLUDES ABOVE AVERAGE

PLUS: Discussion is comprehensive,
cohesive, and interrelated
reflecting thorough chart review and
history taking

Data is complete and accurate re: recent

medical history and reason for
admission
Info is obtained from chart
review, RN, MD and patient/family
interviews
Entire course of hospitalization and
Critical Care Unit stay is
chronologically presented

Required data present

Some limitations in information p
regarding recent medical history, r
admission, or course of hospitaliza

Medical Diagnoses 1%

INCLUDES ABOVE AVERAGE

Complete list of medical diagnoses on

admission
Includes pertinent diagnoses from past
medical/surgical history

Required data present

Some limitations in diagnostic list
past medical/surgical history

* = REFERENCES REQUIRED

Nursing Process Rubric

1
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

Home Medications 1%

INCLUDES ABOVE AVERAGE

Complete and accurate medication list

with therapeutic rationale-indicating
why patient is taking medications

Required data present

Physical Assessment 4%
Vitals signs/Pain assessment
Hemodynamics
EKG strips
O2/Ventilator settings

INCLUDES ABOVE AVERAGE

PLUS: Relates clinical significance of
abnormal assessment findings and
trends to medical diagnoses and
potential complications

Data is complete and accurate in each

category including BSA, BMI, vital
signs, pain assess, O2/Vent settings,
hemodynamic parameters and EKG
strip analysis
Includes significant trends and/ or
changes in physical assessment
Includes interpretation/ analysis of data

Required data present

Some limitations in assessment +/
interpretation

Laboratory Data 3%

INCLUDES ABOVE AVERAGE

PLUS: Relates clinical significance of
abnormal lab values and trends to
medical diagnoses and potential
complications

Complete and accurate lab data with

rationale for all
abnormal values specific to patient
condition
Includes significant trends and/ or
changes in labs
Includes interpretation and analysis of
lab values

Required data present

Some limitations in rationale, tren
data interpretation

ArterialBloodGases 2%

INCLUDES ABOVE AVERAGE

PLUS: Relates clinical significance of
abnormal ABG values to medical
diagnoses and potential complications

Complete and accurate ABG data with

O2/vent settings
Includes interpretation of ABGs

Required data present

Some limitations in ABG data inte

* = REFERENCES REQUIRED

Nursing Process Rubric

2
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

Diagnostic Tests and Procedures

3%

INCLUDES ABOVE AVERAGE

PLUS: Relates clinical significance of
diagnostic test results and procedures
to medical diagnoses, and potential
complications

Complete and accurate diagnostic test

and procedure data with rationale for
tests and interpretation of results

Required data present

Not all diagnostic procedures liste
Some limitations in rationale for p
+/or interpretation of results

Intake /Output Data 1%

INCLUDES ABOVE AVERAGE

Complete and accurate I & O data from

all sources Calculation of past 24 hour
balance
Calculation of 2-3 day prior balance

Required data present

Medications 10%

INCLUDES ABOVE AVERAGE

Complete and accurate med data for all

IV solutions, blood products,
TPN/Lipids, IV hemodynamic drugs,
and all scheduled and prn medications
Accurately calculates constant, rate,
and correct units for all IV
hemodynamic drips infusing
Identifies all IV infusion sites/lines

Required data present

Accurate calculations

* = REFERENCES REQUIRED

All Routine/PRN Meds

ALL IV solutions, All IV meds,
continuous
Infusions, vasoactive drips and
parenteral nutrition

Nursing Process Rubric

3
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

Systems Assessment 20%

INCLUDES ABOVE AVERAGE

PLUS: Assessment reflects
comprehensive documentation of
assessment data Findings are related to
pathophysiology of current condition
and past medical/surgical history

Charting reflects complete and accurate

assessment in all categories appropriate
to patient condition
Appropriate terminology for clinical
charting is used

Required data present

Some limitations in documentation
assessment findings

*Clinical Manifestations of
Current Condition 3%

INCLUDES ABOVE AVERAGE

PLUS: Content reflects
comprehensive list of expected clinical
manifestations according to the
literature
Comparisons are made between
expected and actual findings

Identifies expected clinical

manifestations according to the
literature for each current medical
diagnosis and surgical procedure
Includes key assessment findings on
admission and day of care
Includes clinical judgment re: patient
progress

Required data present

Some limitations in literature refer
+/or clinical judgment

Nursing Clinical Problem List 2%

(Focus of care for day)
FASTERHUGS
Feedings
Analgesia
Sedation
Thrombo prophylaxis
Restraint orders
HOB elevated
Ulcer prophylaxis
Glycemic control
Skin

INCLUDES ABOVE AVERAGE

PLUS: Reflects comprehensive
knowledge and clinical decisionmaking in prioritizing and planning
care
Integrates pathophysiology,
pharmacology, and evidence-based
practice

Complete and accurate nursing clinical

problem list reflects prioritization of
patient family needs related to
assessment and monitoring
interventions, medical/ nursing goals
and plan of care. Integrates evidencebased practice

Required data present

Some limitations in prioritization
problem list
Some limitations in use of evidenc
practice

* = REFERENCES REQUIRED

Nursing Process Rubric

4
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

* Pathophysiology 15%

INCLUDES ABOVE AVERAGE

PLUS: Discussion reflects thorough
understanding of pathophysiology
with expected adaptations and
unexpected responses
Integrates textbook/reference data
with assessment findings and potential
complications
Surgical/interventational procedures
related to pathophysiology are
described

Discussion reflects pathophysiology of

all current conditions and relevant past
medical/ surgical history
Integrates pathophysioly with clinical
manifestations and assessment data
(including lab, diagnostic tests, ABGs
etc.)
Includes interrelationship between
diagnoses

Required data present

Some limitations in integration of
pathophysiology to patients cond

*Potential Complications 2%

INCLUDES ABOVE AVERAGE

PLUS: List reflects comprehensive
understanding of potential
complications for patient
Includes long term complications and
health risk factors

Complete list of potential complications Required data present

related to pathophysiology
Some limitations in list of potentia
complications

* = REFERENCES REQUIRED

Nursing Process Rubric

5
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

*Nursing/Medical
Therapy/Treatments 3%

INCLUDES ABOVE AVERAGE

PLUS: Information reflects
comprehensive clinical knowledge
related to therapies/treatments
Considers other potential collaborative
interventions as appropriate to
therapeutic goals
Provides additional evidence-based
references from articles or
professional websites in addition to
course textbooks

Includes all nursing/medical

therapies/treatments with rationale,
patient application and nursing
implications
Provides textbook and evidence-based
rationale

Required data present

Some limitations on patient applic
nursing implications of therapy
Some limitations in use of evidenc
references

Psychosocial Assessment 2.5%

INCLUDES ABOVE AVERAGE

PLUS: Information reflects
comprehensive psychosocial
assessment
Considers additional psychosocial
issues impacting patient/family as
obtained from patient/family
interviews, clinical rounds, literature
findings etc.

Complete psychosocial assessment

including: individual and/or family
strengths, challenges, and coping
abilities
Complete individual and/or family
cultural assessment and assessment of
health beliefs and values

Required data present

Some limitations in psychosocial
assessment +/or interpretation of a
data

* = REFERENCES REQUIRED

Nursing Process Rubric

6
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

INCLUDES ABOVE AVERAGE

PLUS: Information reflects
comprehensive spiritual assessment
Integrates spiritual assessment
findings with patients health status
Addresses additional areas for spiritual
care interventions

Complete spiritual assessment

including: spiritual strengths,
resources, and needs
Utilizes Taylor (2002) as reference

Required data present

Some limitations in spiritual asses
+/or interpretation of assessment d

* = REFERENCES REQUIRED

Spiritual Assessment 2.5%

Nursing Process Rubric

7
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

INCLUDES ABOVE AVERAGE

PLUS: Care plan is comprehensive
and cohesive with all clinical
assessment data
Provides additional references other
than course textbooks
from articles or websites

Nursing diagnoses are listed in

NANDA and/or collaborative problem
format
Diagnosis include related to and
manifested by
Diagnoses are prioritized
A minimum of 3 problems are
processed (2 physiological and 1
psychosocial or spiritual)
Patient goals/outcomes are measurable
and realistic
Interventions reflect evidence- based
practice and relevant standards of care
Interventions include assessment and
monitoring for potential complications
related to diagnoses, drug therapy, and
treatments
Scientific rationale is provided for all
categories of interventions
Continuity between diagnoses, goals,
interventions, and evaluation
Interventions are evaluated and
modified (actual or potential
modifications)

Required data present

Some limitations in plan of care

* = REFERENCES REQUIRED

*Nursing Diagnoses/
Collaborative Problems
w/ Plan of Care 15%

Nursing Process Rubric

8
Azusa Pacific University 9/10

GRADING CRITERIA
(% OF TOTAL POINTS)

EXCELLENT

ABOVE AVERAGE

AVERAGE

A WORK (90-100%)
[INCLUDES ABOVE AVERAGE
+)

B WORK (80-89.9-%)

C WORK (73-79.9)

DEMONSTRATES ANALYSIS,
SYNTHESIS, AND
INTEGRATION OF COURSE
CONTENT

DEMONSTRATES ANALYSIS AND

INTEGRATION OF COURSE
CONTENT

DEMONSTRATES UNDERSTA
AND APPLICATION OF COUR
CONTENT

Discharge Needs 2.5%

INCLUDES ABOVE AVERAGE

PLUS: Discharge planning is
comprehensive and includes all areas
of concern for patient/family
Utilizes additional resources for
patient/family teaching, referrals, and
follow-up care

Teaching plan is based on identified

educational needs of patient/family
Evaluates teaching provided
Plans for discharge needs
Identifies appropriate referrals and/or
needed follow-up
Identifies plans for long term care and
end of life care as appropriate

Required data present

Some limitations in discharge +/or
plan

References
Format/Appearance 2.5%

INCLUDES ABOVE AVERAGE

PLUS: Utilizes additional textbooks,
articles, or professional websites and
standards of practice as references

UNRS 411 textbooks and articles are

used as references for: current clinical
manifestations, patho, treatments, and
plan of care
References are specific to
patient/family situation
Paper reflects high quality work re:
spelling, grammar, neatness and APA
formatting

Required data present

Some errors in spelling, grammar,
+/or APA formatting

* = REFERENCES REQUIRED

Nursing Process Rubric

9
Azusa Pacific University 9/10