Clinical Scenario 3: Abortion (Spontaneous Miscarriage).

Clinical Scenario 3: Abortion (Spontaneous Miscarriage)

Setting: Emergency Department
Patient: 22-year-old G1P0 at 9 weeks gestation

Chief Complaint:
Ive been cramping and bleeding heavily since this morning.

History & Assessment Findings:

• Heavy vaginal bleeding with clots
• Lower abdominal cramping
• BP: 100/64 mmHg
• HR: 104 bpm
• Reports passing tissue at home
• Cervix: Open (confirmed by provider)
• Ultrasound: No fetal cardiac activity
• The Nursing Process Worksheets assignment is a critical component of each clinical day. (One per Week)Students will select a patient of interest and complete the designated form provided on Canvas. This form includes sections reflecting the nursing process: assessment, diagnosis, planning, implementation, and evaluation, along with areas for documenting subjective and objective patient information. Additionally, the form contains reflective questions to encourage students to analyze their clinical experiences and enhance their critical thinking and self-awareness. Important Reminder: Students must ensure that no patient personal identifiers (e.g., names, medical record numbers, or other identifiable information) are included in their submissions to comply with HIPAA regulations and maintain patient confidentiality. Any violation of HIPAA guidelines will result in appropriate disciplinary actions.The completed worksheet must be submitted via Canvas before the next clinical day. The purpose of this assignment is to integrate theoretical knowledge with clinical practice, foster the development of critical thinking and clinical reasoning, and promote reflective learning to support professional growth and effective patient care.
  

  Rubric

  Nursing Process Worksheet

  Nursing Process Worksheet

  Criteria	Ratings	Pts
  This criterion is linked to a Learning OutcomeIdentification Data	10 ptsExemplary 10 pointsAll data is accurate, complete, and well-organized.7.5 ptsProficient (7.5 points)Most data is accurate and complete; minimal gaps.5 ptsBasic (5 points)Several data points missing or inaccurate.2.5 ptsNeeds Improvement (2.5 points)Critical data is missing or incorrect.	10 pts
  This criterion is linked to a Learning OutcomeChief Complaint & Diagnosis	10 ptsExemplary (10 Points)Clear, detailed, and accurate chief complaint & diagnosis.7.5 ptsProficient (7.5 points)Mostly clear with minor gaps in supporting details.5 ptsBasic (5 points)Vague or incomplete information on the complaint/diagnosis.2.5 ptsNeeds Improvement (2.5 points)Missing or unclear complaint/diagnosis	10 pts
  This criterion is linked to a Learning OutcomePathophysiology	10 ptsExemplary (10 Points)Detailed explanation supported by citations.9.56 ptsProficient (7.5 points)Sufficient explanation with some supporting evidence.5 ptsBasic (5 points)Basic or incomplete pathophysiology explanation.2.5 ptsNeeds Improvement (2.5 points)Pathophysiology is missing or lacks evidence.	10 pts
  This criterion is linked to a Learning OutcomeCurrent Vital Signs & Data	10 ptsExemplary (10 Points)Accurate, complete, and relevant vital signs.7.5 ptsProficient (7.5 points)Mostly accurate, but minor details may be missing.5 ptsBasic (5 points)Several missing or inaccurate vital signs.2.5 ptsNeeds Improvement (2.5 points)Vital signs are mostly missing or incorrect.	10 pts
  This criterion is linked to a Learning OutcomeAnalysis of Assessment Cues	10 ptsExemplary (10 Points)Clear and accurate list of cues with supported analysis.7.5 ptsProficient (7.5 points)Mostly clear analysis with some minor gaps.5 ptsBasic (5 points)Incomplete or unclear data; analysis lacks depth.2.5 ptsNeeds Improvement (2.5 points)Incomplete or disorganized assessment cues.	10 pts
  This criterion is linked to a Learning OutcomePriority Hypothesis/Problem	10 ptsExemplary (10 Points)Clearly identifies and supports priority hypothesis/problem.7.5 ptsProficient (7.5 points)Identifies priority hypothesis with some gaps.5 ptsBasic (5 points)Hypothesis is unclear or unsupported.2.5 ptsNeeds Improvement (2.5 points)Hypothesis is missing or not supported.	10 pts
  This criterion is linked to a Learning OutcomeSMART Goal	10 ptsExemplary (10 Points)Goal is fully SMART (Specific, Measurable, Attainable, Realistic, Timestamped).7.5 ptsProficient (7.5 points)Goal is mostly SMART with minor gaps.5 ptsBasic (5 points)Goal is vague or unrealistic; lacks clarity.2.5 ptsNeeds Improvement (2.5 points)Goal is missing or unclear.	10 pts
  This criterion is linked to a Learning OutcomeImplementation	10 ptsExemplary (10 Points)Four well-developed and appropriate interventions with evidence-based rationale.7.5 ptsProficient (7.5 points)Four interventions, but rationale may lack depth.5 ptsBasic (5 points)Less than four interventions or unclear rationale.2.5 ptsNeeds Improvement (2.5 points)Incomplete, inappropriate, or lack of interventions.	10 pts
  This criterion is linked to a Learning OutcomeEvaluation of Goal	10 ptsExemplary (10 Points)Clear and comprehensive evaluation, with revision suggestions if needed.7.5 ptsProficient (7.5 points)Clear evaluation with some revisions.5 ptsBasic (5 points)Evaluation lacks clarity or justification.2.5 ptsNeeds Improvement (2.5 points)Evaluation is incomplete or lacks reasoning.	10 pts
  This criterion is linked to a Learning OutcomeNursing Application & Reflection	10 ptsExemplary (10 Points)Thorough reflection, clear connections to clinical experience, and NCLEX content.7.5 ptsProficient (7.5 points)Good reflection with some connection to clinical practice.5 ptsBasic (5 points)Limited reflection, unclear connection to clinical experience.2.5 ptsNeeds Improvement (2.5 points)Lacks reflection or connection to clinical practice.	10 pts

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