1. Overview of the situation. All relevant data from case study included. Organized and clear.   Most relevant data from case study considered. Clarity and organization are lacking. Relevant data not included.   2. Relevant assessment data gathered/included. Note: the data you collect in this section will be fictitious. Include relevant, significant (fictious) data collected in this section. A minimum of two evidence-based assessment tools, appropriate to the situation, are used to gather data (findings will be fictious) Focused and relevant physical assessment data (will be fictious) obtained and included. Focused and relevant history (will be fictious) obtained and included. Assessment data is organized in a logical manner, is focused Appropriate assessment tools used. Relevant physical assessment data not focused on the situation. Clarity and organization are lacking.   Summary of findings from evidence based assessment tools not included findings of physical assessment/ health history not included assessment findings not organized or clear   3. Priority nursing concerns identified, supported by data, and justified A minimum of three priority concerns are identified and clearly supported by the data gathered. Priority concerns flow from assessment data included/collected. One concern is a physical; one is psychosocial; the third can be either physical or psychosocial. Priority concerns minimally supported by gathered data. Concerns included, but do not flow from data. Assumptions that could impact care possible.   Priority concerns not supported by data gathered Assumptions that impact care   (these do not need to be written in NANDA format.) Why did you choose these as priority? Priority of chosen concerns is justified and supported with evidence. Explain the reasoning for your prioritization. Reasoning is sound and does not include logical fallacies or assumptions. (8 points) Priorities not adequately justified or supported with evidence   have likely been made Priorities not justified or supported with evidence   4. Goals/desired outcome Goal formulation Desired outcomes/goals clearly flow from assessment data. SMART person and family centered goals/ outcomes for the patient/family are formulated. How did you would go about formulating your goals? (hint: consider principles of person and family centered care and root causes of the nursing concern). One goal/outcome developed to meet each priority concern.   SMART criteria for goals not fully met Evidence that goals are person and family centered is lacking Outcomes/goals do not clearly flow from nursing concerns or outcomes goals do not address root causes   Goals do not meet SMART criteria Not evident that individual /family participated in goal development Goals to not flow from nursing concerns or address root causes   5. Evidence based nursing interventions proposed. A minimum of two interventions flow from each desired goals/outcomes and are supported with professional evidence (note criteria for evidence in the syllabus) Briefly explain how you would develop interventions (Hint: consider principles of person and family centered care and root causes of the nursing concern). Fewer than two interventions clearly flow from each desired outcome or are not supported by scholarly evidence (no citations) or sources do not meet criteria on p. 9 of syllabus Explanation of intervention development to include patient / family centered care care and No evidence based interventions proposed to meet goal. Interventions development does not address patient/family centered care Interventions are individualized and 'fit' with the unique situation. Interventions are specific enough so another nurse could adhere to the plan to facilitate continuity.   /or root causes not included. Interventions do not 'fit' with situation. Interventions not specific enough for another nurse to follow.   principles or root cause analysis Interventions vague   6. Evaluation considered – Addresses how the nurse will evaluate the plan of care and modify as needed. Evaluation not appropriate for unique situation. Evaluation not considered 7. Consideration of rural residence A minimum of two concepts of Rural Health Nursing Theory (find list of these concepts on p. 6 in text edited by Winters) that fit with scenario are explored as they fit with unique patient/ family scenario.   Rural Health Nursing concepts are addressed, but not explored. Concepts do not clearly fit with unique situation. Rural Health Nursing Theory concepts included do not fit with unique situation.   8. Barriers Briefly discuss at least barriers this individual family may encounter while trying to attain their desired quality of life. Supported with evidence.   Barriers listed, but not discussed or not supported with evidence   Barriers listed but not discussed and not supported with evidence.   9. Empowerment Strategies Briefly discuss at least three strategies/interventions a nurse could implement to help this individual family reach the quality of life they desire. Supported with evidence.   Strategies listed, but not discussed or not supported with evidence.   Strategies listed but not discussed and not supported with evidence.   10. Summary statement(s) Gives the paper/plan a sense of completeness. Leaves the reader with a final impression. Sense of completeness lacking. No summary statement(s)   Organization and effectiveness (these criteria are not a specific part of the care plan, but look at the plan as a whole) 9. Resources References drawn from a minimum of three professional nursing journal articles (Note criteria insyllabus) Journal resources are Fewer than three professional nursing journal resources synthesized and integrated Fewer than two professional nursing journal resources synthesized and synthesized and integrated into plan appropriately. integrated 10. Writing quality Plan is clear and focused. Fewer than six punctuation, spelling, spacing, capitalization and writing mechanics errors. Plan lacking in clarity. Fewer than mechanics errors.   Twelve or more writing mechanics errors. 11. APA style Uses APA style correctly for citations and references. Uses headings if writing care plan in narrative format. Fewer than six errors in APA style. Uses headings if writing as narrative. Six or more APA errors errors.

Appendix E - Chronic Illness Family Care Plan Objective: Care plans will be based on the case studies posted in D2L (go to the Chronic Illness Family Careplan folder). Student will synthesize concepts of Rural Nursing Theory, chronic illness, and principles of patient and family centered care with nursing process to plan holistic care for a patient/family living with chronic illness. The plan should be specific enough so that another nurse could adhere to the care plan you wrote – continuity of care is important! Note an optional template is included in the Guidance and Template folder. Please refer to the AGuidance and Template folder for more detail, guidance, and an example. Criterion Excellent Competent Not satisfactory 1. Overview of the situation. All relevant data from case study included. Organized and clear.   Most relevant data from case study considered. Clarity and organization are lacking. Relevant data not included.   2. Relevant assessment data gathered/included. Note: the data you collect in this section will be fictitious. Include relevant, significant (fictious) data collected in this section. A minimum of two evidence-based assessment tools, appropriate to the situation, are used to gather data (findings will be fictious) Focused and relevant physical assessment data (will be fictious) obtained and included. Focused and relevant history (will be fictious) obtained and included. Assessment data is organized in a logical manner, is focused Appropriate assessment tools used. Relevant physical assessment data not focused on the situation. Clarity and organization are lacking.   Summary of findings from evidence based assessment tools not included findings of physical assessment/ health history not included assessment findings not organized or clear   3. Priority nursing concerns identified, supported by data, and justified A minimum of three priority concerns are identified and clearly supported by the data gathered. Priority concerns flow from assessment data included/collected. One concern is a physical; one is psychosocial; the third can be either physical or psychosocial. Priority concerns minimally supported by gathered data. Concerns included, but do not flow from data. Assumptions that could impact care possible.   Priority concerns not supported by data gathered Assumptions that impact care   (these do not need to be written in NANDA format.) Why did you choose these as priority? Priority of chosen concerns is justified and supported with evidence. Explain the reasoning for your prioritization. Reasoning is sound and does not include logical fallacies or assumptions. (8 points) Priorities not adequately justified or supported with evidence   have likely been made Priorities not justified or supported with evidence   4. Goals/desired outcome Goal formulation Desired outcomes/goals clearly flow from assessment data. SMART person and family centered goals/ outcomes for the patient/family are formulated. How did you would go about formulating your goals? (hint: consider principles of person and family centered care and root causes of the nursing concern). One goal/outcome developed to meet each priority concern.   SMART criteria for goals not fully met Evidence that goals are person and family centered is lacking Outcomes/goals do not clearly flow from nursing concerns or outcomes goals do not address root causes   Goals do not meet SMART criteria Not evident that individual /family participated in goal development Goals to not flow from nursing concerns or address root causes   5. Evidence based nursing interventions proposed. A minimum of two interventions flow from each desired goals/outcomes and are supported with professional evidence (note criteria for evidence in the syllabus) Briefly explain how you would develop interventions (Hint: consider principles of person and family centered care and root causes of the nursing concern). Fewer than two interventions clearly flow from each desired outcome or are not supported by scholarly evidence (no citations) or sources do not meet criteria on p. 9 of syllabus Explanation of intervention development to include patient / family centered care care and No evidence based interventions proposed to meet goal. Interventions development does not address patient/family centered care Interventions are individualized and 'fit' with the unique situation. Interventions are specific enough so another nurse could adhere to the plan to facilitate continuity.   /or root causes not included. Interventions do not 'fit' with situation. Interventions not specific enough for another nurse to follow.   principles or root cause analysis Interventions vague   6. Evaluation considered – Addresses how the nurse will evaluate the plan of care and modify as needed. Evaluation not appropriate for unique situation. Evaluation not considered 7. Consideration of rural residence A minimum of two concepts of Rural Health Nursing Theory (find list of these concepts on p. 6 in text edited by Winters) that fit with scenario are explored as they fit with unique patient/ family scenario.   Rural Health Nursing concepts are addressed, but not explored. Concepts do not clearly fit with unique situation. Rural Health Nursing Theory concepts included do not fit with unique situation.   8. Barriers Briefly discuss at least barriers this individual family may encounter while trying to attain their desired quality of life. Supported with evidence.   Barriers listed, but not discussed or not supported with evidence   Barriers listed but not discussed and not supported with evidence.   9. Empowerment Strategies Briefly discuss at least three strategies/interventions a nurse could implement to help this individual family reach the quality of life they desire. Supported with evidence.   Strategies listed, but not discussed or not supported with evidence.   Strategies listed but not discussed and not supported with evidence.   10. Summary statement(s) Gives the paper/plan a sense of completeness. Leaves the reader with a final impression. Sense of completeness lacking. No summary statement(s)   Organization and effectiveness (these criteria are not a specific part of the care plan, but look at the plan as a whole) 9. Resources References drawn from a minimum of three professional nursing journal articles (Note criteria insyllabus) Journal resources are Fewer than three professional nursing journal resources synthesized and integrated Fewer than two professional nursing journal resources synthesized and synthesized and integrated into plan appropriately. integrated 10. Writing quality Plan is clear and focused. Fewer than six punctuation, spelling, spacing, capitalization and writing mechanics errors. Plan lacking in clarity. Fewer than mechanics errors.   Twelve or more writing mechanics errors. 11. APA style Uses APA style correctly for citations and references. Uses headings if writing care plan in narrative format. Fewer than six errors in APA style. Uses headings if writing as narrative. Six or more APA errors errors.