GRADING RUBRIC FOR CONCEPT CARE MAPS

CRITERIA

INCOMPLETE
1 POINTS

POOR
2 POINTS

Assessment
Includes subjective, objective and
historical data that support actual or
risk for nursing diagnosis. Includes
pathophysiology of underlying disease
with reference from approved source.

Assessment portion
is incomplete.
Pathophysiology
portion is
incomplete.

Does not include all pertinent

data related to nursing
diagnosis. May also include
data that does not relate to
nursing diagnosis. Does not
include pathophysiology of
underlying disease.

Diagnosis
Includes the most appropriate nursing
diagnosis for patient that includes all
appropriate parts (stem, related to or
R/T, and as evidenced by AEB for
actual diagnosis) and is NANDA
approved.
Planning (Goal Setting)
Includes a patient or family goal that is
most appropriate for the patient/family
and the nursing diagnosis. Goal must
be reasonable, measurable, specific,
patient centered and have a target
time.
Implementation (Interventions)
Includes interventions or nursing
actions that directly relate to the
patient's goal, that are specific in
action and frequency, and include
rationale. Number of interventions
should be appropriate to help patient
or family meet their goal. Preferred: 3
clinical and 3 educational interventions.
Evaluation
Includes data that is listed as criteria in
goal statement. Based on this data,
goal is determined to be met, partially
met, or not met. If goal was not met or
partially met, student will provide an
explanation.

Diagnosis portion is
incomplete.

Diagnosis is not appropriate

for patient. May also not be
NANDA approved and may not
include all parts.

Goal portion is
incomplete.

FAIR
3 POINTS

GOOD
4 POINTS

Includes all pertinent data

related to nursing diagnosis,
but also includes data not
related to nursing diagnosis.
Includes pathophysiology of
underlying disease without
reference from approved
source.
Diagnosis is appropriate for
patient and diagnosis is
NANDA approved, but does
not include all parts or
information is listed in wrong
part of diagnosis.

Includes all pertinent data related to

nursing diagnosis and does not
include data that is not related to
nursing diagnosis. Includes
pathophysiology of underlying
disease with reference from
approved source.

Goal statement is not patient

or family centered and may
not be reasonable, specific, be
measurable, or have a target
time.

Goal statement is patient or

family centered, is reasonable
and specific but may not be
measurable or have a target
time.

Goal statement is patient or family

centered, reasonable, specific,
measurable, and has a target time.

Interventions
portion is
incomplete.

Interventions portion does not

include adequate number of
interventions to help
patient/family meet goal.
Interventions may also not be
specific or listed with
rationales.

Interventions portion contains

adequate number of
interventions to help
patient/family meet goal, but
interventions may not be
specific or listed with
rationales.

Interventions portion contains

adequate number of interventions to
help patient/family meet goal, and
interventions are specific in action
and frequency and are listed with
rationales.

Evaluations portion
is incomplete.

Evaluation portion does not

contain data that is listed as
criteria in goal statement. May
also not describe goal as met,
partially met, or not met. May
also not include explanation
why goal not met.

Evaluation portion does

contain data that is listed as
criteria in goal statement, but
does not describe goal as met,
partially met, or not met. May
also not include explanation
why goal not met.

Evaluation portion does contain data

that is listed as criteria in goal
statement. Does describe goal as
met, partially met, or not met. If
goal was partially met or not met,
includes explanation why goal not
met.

Diagnosis is appropriate for patient

and diagnosis is NANDA approved.
Diagnosis also includes all parts and
information is listed in correct part of
diagnosis.

Total for each column

Place a check mark in the appropriate box for each criteria, total each column and place the Total Score here___________
Total Score possible = 20 points.

CONCEPT CARE MAP

Implementation
Assess pain intensity using
a numeric pain scale. (0-10)
Manage chronic pain using
a multimodal approach.
Review clients pain diary,
flow sheet, and medication
records to determine
overall degree of pain relief,
side effects and analgesic
requirements for an
appropriate period.
__________________________
Teach patient to use the
self-report pain tool to rate
the intensity of past or
current pain. Ask client to
set a comfort-function goal
by selecting a pain level on
the self-report tool that will
allow performance of ADLs
with relative ease.
Teach client by reinforcing
the importance of taking
pain medications to
maintain the comfortfunction goal.
Demonstrate the use of
appropriate nonpharmacologic approaches
in addition to
pharmacologic approaches
to help control pain (such
as heat and cold,

Pathophysiology of underlying
disease

Assessment
Subjective Data: Patient states pain is 6/10.
Reports discomfort in his knee
Objective Data: Patient diagnosed with
staphylococcus arthritis (septic joint) of the right
knee. Arthroscopic surgery was performed on 4/21.
Knee is swollen, red, and warm.
Pertinent medical/surgical history: Gout,
Coronary Heart Disease, high cholesterol

A septic joint occurs when

bacteria enters the joint space
causing an inflammatory
response. This causes the
release of cytokines within the
synovial membrane lead to
joint destruction.
Staphylococcus is the most
common bacteria to cause a
septic joint.

Diagnosis/Planning
Nursing diagnosis: Chronic Pain related to inflammation of infected
joint as evidenced by septic joint.
Patient Goal: Get pain to a manageable level (less than 4)

Goldenberg, D. L. (1998). Septic

arthritis. The
Lancet, 351(9097), 197202. doi:10.1016/s01406736(97)09522-6

Evaluation
Patients goal was met.
The patients pain scale at
the end of my shift was a
2/10.