Qatar University
College of Nursing
Assessment: subjective and
objective (3pts)
Diagnosis: problem, etiology,
and the defining
characteristics (1pts)
Client Goals/Desired
Outcomes/Objectives:
SMART (1pts)
Nursing
Interventions/Actions/Orders,
and Rational
(3pts)
Outcome/ Evaluation (1pts)
Evidence
Department of Clinical Affairs
NURS202 Care Plan Grading Rubric
Below Standard
0-1 point
Data is incomplete and/or does not support
nursing diagnosis.
0-1 point
Diagnosis fails to identify key problem.
Diagnosis not clearly stated with irrelevant
etiology and/or contributing factors.
0-1 point
Goals are unrealistic and/or ambiguous.
Missing STG and/or LTG.
0-1 point
Interventions are unclear and do not
support goal(s).
Scientific rationale/evidence incomplete
and does not support intervention.
0-1 point
Goal and/or objective evaluation is
incomplete.
0-1 point
No evidence or evidence for only one of
Meets Standard
1-2 points
Limited data to support nursing
diagnosis.
1-2 points
Diagnosis stated without
etiology or contributing factors
thoroughly identified.
1-2 points
STG and LTG are realistic and
precise. Unspecific time frame
or method to measure outcome.
1-2 points
Interventions support goals but
are limited and/or non-specific.
Rationales/evidence included
for each intervention with
limited support.
1-2 points
Limited evaluation of objective
and/or goal.
1-2 point
Evidence for 2-3 of the
1
Exceeds Standard
2-3 points
Includes relevant subjective and objective
data. Data supports nursing diagnosis.
2-3 points
Diagnosis identifies key problem from
presented assessment data.
Diagnosis is clearly structured and includes
relevant etiology and contributing factors.
2-3 points
Goals are realistic, precise, and measurable.
Includes STG and LTG for each diagnosis
with stated time frame.
2-3 points
Interventions support goals and are
comprehensive and precise.
Each intervention includes scientific
rationale/evidence. Clearly related to
intervention
2-3 points
Clearly evaluates each objective and/or goal,
with client response to goal.
2-3 point
Evidence for all of the following is provided:
outcomes, intervention, rationales, and
the following is provided: desired following is provided: desired evaluation.
outcomes, interventions, rationales, and outcomes, interventions,
evaluation. rationale, and evaluation.

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 Qatar University
College of Nursing
Department of Clinical Affairs
NURS 202 Care Plan

Patient/Client’s initials: M.H Age: 62 Gender: Male Room/Bed: 507-4

Medical Diagnosis: Diabetic Foot ulcers

Nursing
Client Goals/Desired Outcome/
Assessment Nursing Diagnosis Interventions/Action Rationale
Outcomes/Objectives Evaluation
s/Orders
Subjective (1.5p) Problem (1p) Short Term: (1p) I: (1.5p) R: (1.5p) (1p)
 Patients  Impaired  Promote wound  Encourage the  These exercises enhance  Met: The patient
reported Physical healing and strive for patient to engage general tissue health and actively participated in
localized pain Mobility observable in range-of- reduce problems by (ROM) exercises,
on their right improvements in the motion exercises improving circulation, which enhanced
leg. R/T (0.5p) ulcer's appearance and offer advice tissue oxygenation, and circulation and
 Decreased  Amputation of within a short period. on appropriate pressure distribution. mobility. Regular
muscle the right foot  Attempt to increase form and (Qiu et al.,2022)
dressing changes,
strength in the movement while frequency.  Changing the dressing
proper use of topical
right leg AEB (0.5p) lowering the  Changing and using the right
medicines, and careful
 Limited range possibility of applying dressings on a topical medications
of motion pressure to the injured regular basis, helps to keep the wound observation were all
Objective (1.5p)  Expresses region. using topical environment clean, stop practised. Pain
 Patient discomfort therapies problems, and speed up treatments successfully
glucose is when moving Long Term: appropriately, and the healing process. decreased discomfort
very high.  Use of  Maintain an ulcer-free keeping an eye (Moore et al.,2018) associated with ulcers.
 Elevated assistive foot by consistently out for problems  According to Paschou et
heart rate 120 devices implementing infection or infection al. (2018), pain  Partially met: The
PMR  Inability to prevention measures symptoms. management techniques patient only partially
 Regular bear weight. and proper wound care.  pain management are critical to raising followed through on
temperature:  Encourage the patient techniques, such patients' quality of life the ROM exercises.
36.5 °C to adopt long-term as using topical and encouraging them to While topical
 Soaked lifestyle modifications medications or follow wound care treatments and
dressing to enhance general prescription instructions. These dressings were applied
 BP: 110/80 health and lower the analgesics, help techniques help patients appropriately, careful
 SpO2:99% risk of foot ulcers, such reduce ulcer- feel better by relieving monitoring was not

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 as dietary alterations related pain and improving their
and frequent exercise. discomfort. mobility, comfort, and
general contentment.
These factors are all
critical to the healing of
wounds and the
provision of patient-  Not met: There were
centered care.
always maintained.
Although they weren't
entirely successful,
pain management
measures did offer
some alleviation.
no (ROM) exercises
performed by the
patient. Inadequate
monitoring,
inappropriate topical
therapy application,
and missed dressing
changes all occurred.
Techniques for
managing pain were
ineffectual.

References:
1- Qiu, Y., Osadnik, C. R., Team, V., & Weller, C. D. (2022). Effects of physical activity as an adjunct treatment on healing outcomes and
recurrence of venous leg ulcers: A scoping review. Wound repair and regeneration : official publication of the Wound Healing Society
[and] the European Tissue Repair Society, 30(2), 172–185. https://doi.org/10.1111/wrr.12995

2- Moore, Z. E., & Webster, J. (2018). Dressings and topical agents for preventing pressure ulcers. The Cochrane database of systematic
reviews, 12(12), CD009362. https://doi.org/10.1002/14651858.CD009362.pub3

3- Paschou, S. A., Stamou, M., Vuagnat, H., Tentolouris, N., & Jude, E. (2018). Pain management of chronic wounds: Diabetic ulcers and
beyond. Maturitas, 117, 17–21. https://doi.org/10.1016/j.maturitas.2018.08.013

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