Individual Care Map Evaluation Tool – NSG240/315/430 Name: _______________________ Date: ___________ Patient’s initials: _______________ Concept 240/315/430 (Follow instructions provided and on Moodle) The student will: Maxi-mum Points/ Prepare: Written Analysis and Concept Map Student points Unsatisfactory Basic Satisfactory Exceeds expectations Comments: Conduct and describe a thorough history and physical (Medical diagnosis, Lab and diagnostic tests, physician's orders) History and physical with many errors and components not addressed. (2 pts) Partially conducts and describes history and physical with <80% accuracy. (5 pts) Conducts and describes thorough history and physical. All components complete. (8 pts) Conducts and describes thorough history and physical. All components complete and individualized to patient. (10 pts) Prepare: a table describing the pharmacotherapies: Medication, dose, frequency, route, class, top 3 side effects, indications Table of pharmacologic interventions with many errors of omission and content accuracy. (2 pts) Prepares a partially complete table of pharmacologic interventions with <80% accurate content. (5 pts) Prepares a complete and accurate table of pharmacologic interventions. (8 pts) Prepares a complete and accurate table of pharmacologic interventions. Indications are individualized for the patient.(10 pts) Demonstrate appropriate use of Gordon's Functional Patterns (GP) by organizing data into meaningful data clusters to determine associated nursing diagnosis (NDx). Data disorganized; GP not identified or not with appropriate data clusters; NDx do not reflect understanding of client problems. (1 pt) 60-80% of data organized and clustered; <80% of GP supported; NDx partially reflects understanding of client needs. (2 pts) 80-90% of data organized and clustered; 80-90% of GP identified with supportive data clusters; NDx identified reflect understanding of client problems. (4 pts) All data organized and clustered to represent 100% of Gordon's functional patterns; associated NDx identified reflect understanding of client problems. (5 pts) List at least 3 Nursing Diagnoses (NDx) based upon analysis of the data (must have at least 1 actual physiological, 1 psychosocial, and 1 educational nursing diagnosis clearly identified). All identified NDx listed from highest priority to lowest priority. Does not have required number or types of NDx; NDx not written in correct format; NDx not listed from highest to lowest priority. (2 pts) ≤ 3 NDx listed based upon analysis of the data; does not include at least 1 actual physiological, 1 psychosocial, and 1 educational NDx; < 80% of NDx statements reflect correct formatting; <80% identified NDx listed from highest priority to lowest priority. (5 pts) 3 NDx listed based upon analysis of the data; includes at least 1 actual physiological, 1 psychosocial, and 1 educational NDx; All parts of the NDx st ...

1. Individual Care Map Evaluation Tool – NSG240/315/430
Name: _______________________ Date: ___________
Patient’s initials: _______________
Concept
240/315/430
(Follow instructions provided and on Moodle)
The student will:
Maxi-mum Points/
Prepare: Written Analysis and Concept Map
Student points
Unsatisfactory
Basic
Satisfactory
Exceeds expectations
Comments:
Conduct and describe a thorough history and physical (Medical

2. diagnosis, Lab and diagnostic tests, physician's orders)
History and physical with many errors and components not
addressed. (2 pts)
Partially conducts and describes history and physical with <80%
accuracy. (5 pts)
Conducts and describes thorough history and physical. All
components complete. (8 pts)
Conducts and describes thorough history and physical. All
components complete and individualized to patient. (10 pts)
Prepare: a table describing the pharmacotherapies: Medication,
dose, frequency, route, class, top 3 side effects, indications
Table of pharmacologic interventions with many errors of
omission and content accuracy. (2 pts)
Prepares a partially complete table of pharmacologic
interventions with <80% accurate content. (5 pts)
Prepares a complete and accurate table of pharmacologic
interventions. (8 pts)
Prepares a complete and accurate table of pharmacologic
interventions. Indications are individualized for the patient.(10
pts)
Demonstrate appropriate use of Gordon's Functional Patterns
(GP) by organizing data into meaningful data clusters to
determine associated nursing diagnosis (NDx).
Data disorganized; GP not identified or not with appropriate
data clusters; NDx do not reflect understanding of client
problems. (1 pt)
60-80% of data organized and clustered; <80% of GP supported;
NDx partially reflects understanding of client needs. (2 pts)
80-90% of data organized and clustered; 80-90% of GP
identified with supportive data clusters; NDx identified reflect
understanding of client problems. (4 pts)

3. All data organized and clustered to represent 100% of Gordon's
functional patterns; associated NDx identified reflect
understanding of client problems. (5 pts)
List at least 3 Nursing Diagnoses (NDx) based upon analysis of
the data (must have at least 1 actual physiological, 1
psychosocial, and 1 educational nursing diagnosis clearly
identified). All identified NDx listed from highest priority to
lowest priority.
Does not have required number or types of NDx; NDx not
written in correct format; NDx not listed from highest to lowest
priority. (2 pts)
≤ 3 NDx listed based upon analysis of the data; does not include
at least 1 actual physiological, 1 psychosocial, and 1
educational NDx; < 80% of NDx statements reflect correct
formatting; <80% identified NDx listed from highest priority to
lowest priority. (5 pts)
3 NDx listed based upon analysis of the data; includes at least 1
actual physiological, 1 psychosocial, and 1 educational NDx;
All parts of the NDx statements reflect correct formatting; All
identified NDx listed from highest priority to lowest priority.
(8pts)
4 (four) or more NDx listed based upon analysis of the data;
includes at least 1 actual physiological, 1 psychosocial, and 1
educational NDx; All parts of the NDx statements reflect
correct formatting; All identified nursing diagnoses listed from
highest priority to lowest priority. (10 pts)
Answer the required questions in a separate document by
Explaining the data to identify the human responses to a given
health situation and determine the priority client needs based
upon clusters of relevant data and Gordon’s Patterns. Methods
of prioritization of the nursing diagnoses discussed and diagram
provided. Questions that must be answered are provided in the
instructions and are required as the header for each section.

4. Does not explain components of the care planning process;
Components missing; Methods of prioritization not discussed.
(2 pts)
Explanation of components of care planning process partially
met; Questions head each section; Diagrams are missing or do
not add to the planning process. (5 pts)
Provides detailed and insightful explanation of 80-90% of
components of care planning process; Questions head each
section; Diagrams are easily understood and support. (8 pts)
Provides detailed and insightful explanation of all components
of care planning process; Questions head each section;
Diagrams are easily understood and support. Care plan
individualized for the patient. (10 pts)
Demonstrate appropriate use of nursing process: Select and
prepare a plan of care for the patient's priority Physiological
NDx identified. All components included:
• NDx with all relevant data;
• Patient-centered goal (measurable and timeframe);
• Patient-centered expected outcomes in SMART format;
• 3 or more nursing interventions with evidence based (EBP)
rationale and citation;
• Evaluation of interventions and whether met/unmet/partially
met with plan for revision.
Does not reflect priority physiological NDx. Components of
nursing process with incomplete or inaccurate informatio n.
Does not demonstrate appropriate use of nursing process. (5
pts)
Priority physiological NDx correctly identified. < 80%% of
components of nursing process present on the care map with
complete and accurate information. 2 or more expected
outcomes; 3 or more interventions selected. (12 pts)
Priority physiological NDx correctly identified. All

5. components of nursing process present on the care map with
complete and accurate information. 2 or more expected
outcomes showing goal achievement; 3 or more individualized
interventions selected. (16 pts)
Priority physiological NDx correctly identified. All components
of nursing process present on the care map with complete and
accurate information. 4 or more individualized interventions
selected. (20 pts)
Demonstrate appropriate use of nursing process: Select and
prepare a plan of care for the patient's priority Psychosocial
NDx identified. All components included:
• NDx with all relevant data;
• Patient-centered goal (measurable and timeframe);
• 2 Patient-centered expected outcomes in SMART format;
• 3 or more nursing interventions with evidence based (EBP)
rationale and citation;
• Evaluation of interventions and whether met/unmet/partially
met with plan for revision.
Does not reflect priority psychosocial NDx. Components of
nursing process with incomplete or inaccurate information.
Does not demonstrate appropriate use of nursing process. (5
pts)
Priority psychosocial NDx correctly identified. < 80% of
components of nursing process present on the care map with
complete and accurate information. 2 or more expected
outcomes; 3 or more interventions selected without evidence-
based rationale. (12pts)
Priority psychosocial NDx correctly identified. All components
of nursing process present on the care map with complete and
accurate information. 2 or more expected outcomes showing
goal achievement; 3 or more individualized interventions
selected. (16 pts)
Priority psychosocial NDx correctly identified. All components

6. of nursing process present on the care map with complete and
accurate information. 3 or more expected outcomes showing
goal achievement; 4 or more individualized interventions
selected. (20pts)
NSG 315 and 430 only: Demonstrate appropriate use of
nursing process: Select and prepare a plan of care for the
patient's priority Educational NDx identified. All components
included:
• NDx with all relevant data;
• Patient-centered goal (measurable and timeframe);
• Patient-centered expected outcomes in SMART format;
• 3 or more nursing interventions with evidence based (EBP)
rationale and citation;
• Evaluation of interventions and whether met/unmet/partially
met with plan for revision.
Does not reflect priority educational NDx. Components of
nursing process with incomplete or inaccurate information.
Does not demonstrate appropriate use of nursing process. (5
pts)
Priority educational NDx correctly identified. < 80% of
components of nursing process present on the care map with
complete and accurate information. 2 or more expected
outcomes; 3 or more interventions selected without evidence-
based rationale. (12 pts)
Priority educational NDx correctly identified. All components
of nursing process present on the care map with complete and
accurate information. 2 or more expected outcomes showing
goal achievement; 3 or more individualized interventions
selected. (16 pts)
Priority educational NDx correctly identified. All components
of nursing process present on the care map with complete and
accurate information. 3 or more expected outcomes showing

7. goal achievement; 4 or more individualized interventions
selected. (20pts)
Use Care Map to Cluster and Analyze Data
Create and format a client care map relevant to the patient's
presenting problems.

8. Data clusters disorganized and does not show critical thinking
leading to identification of human response to the situation.
Relationships between concepts with Care Map format poorly
indicated. (2pts)
Non-patient-centered care map developed. All components of
nursing process are identified and incorporated into the care
map. . Data cues organized data clusters which reveal Patterns
of function dysfunction. OR Relationships between concepts
ambiguous. Does not show critical thinking leading to the
identification of the priority NDx. (5pts)
Patient-centered care map developed. All components of nursing
process are identified and incorporated into the care map. Data
clusters which reveal Patterns of function or dysfunction.
Relationships between concepts clearly indicated to include
influences, results, and how each step of the nurse process
affects the others. Does not show critical thinking leading to the
identification of the priority NDx (8pts)
Patient-centered care map developed. All components of nursing
process are identified and incorporated into the care map. Data
clusters reveal Patterns of function or dysfunction (labeled).
Relationships between concepts clearly indicated to include
influences, results, and how each step of the nursing process
affects the others. Demonstrates critical thinking leading to the
identification of the priority NDx. (10pts)
Communicate knowledge in a manner that is concise, balanced,
and logically organized; Demonstrates professional writing and
communication skills to explain planning of care
Does not communicate knowledge in a manner that is concise,
balanced, and logically organized; does not demonstrate
professional writing and communication skills; does not apply
APA style and formatting for references and citations. (0 pts.)
Partially communicates knowledge in a manner that is concise,
balanced, and logically organized; Partially demonstrates

9. professional writing and communication skills to explain
planning of care; applies APA style and formatting; assignment
contains > 20% errors. (2 pts)
Communicates knowledge in a manner that is concise, balanced,
and logically organized; Demonstrates professional writing and
communication skills to explain planning of care; applies APA
style and formatting for references and citations with ≤
20% errors. (4 pts)
Communicates knowledge in a manner that is concise, balanced,
and logically organized; Demonstrates professional writing and
communication skills to explain planning of care; applies APA
style and formatting for references and citations with no
errors.(5 pts)
Total Points Available (NSG 240)
100
Total Points Available (NSG 315 and NSG 430)
120
Satisfactory (80 points NSG 240)
Satisfactory (96 points NSG 315 and 430)
If satisfactory not met, correct named deficiencies and resubmit
for further evaluation on ________ Initials____________
Faculty signature: ______________________ Student

10. signature: __________________________
2.20.18 df
School of Nursing
Care Mapping 240/315/430
(Attachment 7)
Building upon the learning process for planning care through
care mapping in NSG 110 and NSG 120, each student will
create at least one care map in each clinical.
Select the patient from the clinical rotation and obtain approval
from your clinical instructor to assure this patient is appropriate
for the care mapping assignment.
Using the Care Map Template create a plan of care map of a
select patient. Students’ name must be on the care map and the
write up of the questions.
Steps in care mapping (each section shall include the complete
and accurate patient information):
1. Identify the patient’s medical diagnosis, problem, or reason
for seeking health/medical care. (By week 4)
Medical Diagnosis A description of the problem or reason for
seeking care.
This portion should include:
· pathophysiology-include a description of what the disease
process is, who does it affect and when, where does it affect
them and why it affects them (risk factors)
· signs and symptoms of the disease/disorder
· how the disease/disorder is diagnosed
· and typical treatment (medical and surgical)
2. Nursing Assessment. This is the patient assessment by the
student nurse and it comes from a variety of sources:
History and Physical Assessment Findings:

11. History: Genitourinary:
Neuro/Sensory/Mental Status: Gastrointestinal:
HEENT: Integumentary:
Cardiac: Musculoskeletal:
Respiratory: Reproductive:
Emotional/Social/Spiritual:
***Physical assessment should involve inspection, auscul tation,
palpation & percussion.
Laboratory and diagnostic tests
Pharmacologic therapies in a table: (Medication name,
individualized indications, dose, route, frequency, time, top
three side effects pertinent to the medication, contraindications,
if any)
3. Assessment Analysis - Analyze the data gathered (learned in
NSG 110):
· Cluster the data into patterns and identify the Gordon’s
Functional Health Patterns. Indicate whether the pattern is
functional or dysfunctional.
· Determine Associate Nursing Diagnoses based upon the
Selected Gordon’s Patterns
4. Identify nursing diagnoses (problems that represent the
patient’s responses to the medical diagnosis).
· Nursing Diagnosis (NANDA)
· Related to (what factors are causing the problem)
_______________________________
· As evidenced by (assessment findings- the evidence that a
problem is occurring)
***Reminder to review the parts of a Problem-Oriented
diagnosis, a Risk diagnosis, and a Health Promotion diagnosis.
5. Select the Priority Problems in each Category: Physiological,
Psychosocial and Educational needs (only NSG 315 and NSG
430)

12. 6. Develop plans of care in the appropriate template to alleviate
the problems Each plan must have the following:
a. an appropriate nursing diagnosis,
b. patient-centered goal statement,
c. Patient-centered SMART outcomes,
d. evidence-based interventions,
e. and evaluation criteria.
***Reminder about steps in the nursing process as learned in
NSG 110:
· Goals are broad, measurable, patient-centered statement.
· Outcomes are specific, measurable, realistic and concise steps
that the patient must accomplish to achieve the general goal.
Outcomes should flow from the nursing diagnosis. The student
should aim to alleviate the problems identified in the “As
Evidenced By” portion of the nursing diagnosis.
· Each Nursing Intervention shall include evidence-based
rationale with citation in APA format. Interventions should be
individualized to the patient’s needs to resolve the problem.
· Patient education and discharge planning should be included
in the interventions.
· Evaluation criteria should state whether the outcomes are met.
If outcomes have not been met, how are you going to revise the
plan of care?
7. Students shall answer the questions at the end of the care map
template using appropriate grammar, spelling, and syntax.
Additional instructions for writing the paper are on the template
and below:
Write about what you just did and how you thought about it.
Each Gordon’s Functional Pattern set shall be a paragraph.
Describe the thinking you did to develop the associated nursing
diagnoses for that data cluster set. Then, move on to the next
data cluster and make that a new paragraph. Don’t assume your

13. instructor knows anything about your thought process, because
they don’t. Show your instructor how you are thinking! How to
begin…………….
On a separate page: Name and date; include ALL of the
questions with the Answers of the questions:
1. In separate paragraphs, explain the data clusters and which
Gordon’s pattern is represented by each data cluster. Which
Gordon’s Patterns are Functional or Dysfunctional? (Take each
of the data clusters and discuss how they helped.)
2. Using Gordon’s as a guide, explain which nursing diagnoses
are identified for this client? (Separate each Gordon’s pattern
into a paragraph).
3. List the identified nursing diagnoses in priority order in the:
“Problem” Related to “_____ “ Evidenced by “____”
format.
4. Which nursing diagnosis is most important to address with
this client? Explain how this was determined.
5. Which nursing diagnosis is second most important to address
with this client? Explain how this was determined.
6. Which nursing diagnosis is least important to address with
this client? Explain how this was determined.
7. Describe the evaluation of the client for each nursing
diagnosis?
· Care maps are due in week 6 and student must earn ≥ 80%
(within two attempts) to pass the care map and clinical portion
of the course.
· Should a revision of the clinical care map be required, the
revision is due in week 8.
Be prepared to present your concept map to your fellow students
during post conference the last week time permitting.

14. All material that is not original work shall be referenced in APA
format with appropriate in-text citations. Work that is not
original and not referenced will not be graded and could result
in a grade of zero.
The concept map is supporting documentation for you to use to
develop a plan of care specific to your patient and justifies
everything you do for your patient.
It should be specific enough that you could hand it to another
nurse so the care for your patient could be continued.
The concept map is a written version of the nursing process and
it is “used to organize patient data, analyze relationships in the
data, establish priorities, build on previous knowledge, identify
what you do not understand, and enable you to take a holistic
view of the patient’s situation (Schuster, 2002).”
The nursing process involves critical thinking and is the
foundation of what nurses do. The steps are:
· Assessment- gathering clinical data from a variety of sources
to support the decisions you make about the patient.
· Diagnosing- identifying problems that represent the patient’s
responses to the medical diagnosis, problem, or reason for
seeking care.
· Planning- developing a plan, with goals, to alleviate the
problems.
· Implementing- providing the care based on the plan you
created.

15. · Evaluating- reviewing the care you provided and determining
whether the care provided has alleviated the patient’s problems
and that the goals you set have been reached.
Concept map template
Nsg110
Nsg 120
Nsg 240/245/430
Assessment
Subjective /objective data
Body Systems
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Patient
Gordon Pattern and cluster data
Gordon Pattern and cluster data
medications
List doctors order
Labs/xrays
Nursing 240/245/430
Page 1
pathophysiology
Intervention and rational
Evaluation
Educational Nsg Dx
Goal/outcome
Psychosocial Nsg Dx

16. Physiological Nsg Dx
Goal/outcome
Goal/outcome
Intervention and rational
Intervention and rational
Evaluation
Evaluation
Nursing 240/245/430
Page 2
Write about what you just did and how you thought about it.
Each Gordon’s Patterns set shall be a paragraph. Tell me about
all the thinking you did to develop the associated nursing
diagnoses for that data cluster set. Then, move on to the next
data cluster and make that a new paragraph. Don’t assume I
know anything about your thought process, because I don’t.
Show me how you are thinking! How to begin…………….
Include ALL of the questions with the Answers of the questions:
In separate paragraphs, explain the data clusters and which
Gordon’s pattern is represented by each data cluster. Which
Gordon’s patterns are Functional or Dysfunctional? (Take each
of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, which nursing diagnoses are
identified for this client? (Separate each Gordon’s pattern into a
paragraph).
List the identified nursing diagnoses in the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this
client? Explain how this was determined.
Which nursing diagnosis is second most important to address
with this client? Explain how this was determined.
Which nursing diagnosis is least important to address with this
client? Explain how this was determined.

17. Answer questions
Nursing 240/245/430
Page 3
Select the priority physiological and psychosocial (NSG240)
and educational (NSG245 and NSG430) Nursing diagnoses.
Complete the Nursing process by answering the questions below
and including the information in the explanation paper for each
priority nursing diagnosis:
What is the goal for the client to show that the priority problem
is reduced or resolved?
What would a nurse (you) need to do for the client to help the
client meet the goal?
How would you know that the client has met the goal?
Nursing 240/245/430
Page 4
References
Nursing 240/245/430
Page 5