Clinical Reasoning Assignment: Patient Scenario and Nursing Care

The purpose of the Clinical Reasoning Assignment is to examine a patient scenario and develop clinical reasoning. Through identifying the patient problem, labs, assessment, medical management, education priorities, discharge planning, as well as quality and safety measures of nursing by;

1. Demonstrate responsibility and accountability while providing patient-centered care within the scope of practice of the associate degree nurse. 
2. Demonstrate proficient use of technology and incorporation of evidence-based practices to support safe, effective, quality patient care. 
3. Function proficiently within inter/intra-professional teams to achieve quality patient care.
4. Provide individualized care based on patient values and evidence-based practices to improve quality and the delivery of safe patient care.
5. Utilize the nursing process to provide ethical, culturally competent and holistic care for adults experiencing complex alterations in health.
6. Formulate individualized teaching plans for patients with complex alterations in health in collaboration with patients, families and the inter/intra-professional team.
7. Prioritize nursing care provided to individuals from culturally and ethnically diverse backgrounds experiencing complex alterations in health.

1. Identify the history of present problem.
2. Identify relevant data from history and provide rationale (Pathophysiology).
3. Identify the relationship between the patient past medical history and home meds (including medication classification and expected outcomes).
4. Identify which disease process likely developed first and the initiated a “domino effect” in patient life.
5. Identify current vitals and pain assessment.
6. Describe what vital sign data is relevant as clinically significant to the nurse (include rationale).
7. Identify assessment data.
8. Describe what assessment data is relevant and clinically significant to the nurse (include rationale).
9. Identify vital signs and relationship to primary problem/nursing priority.
10.Identify relevant nursing assessment data and relationship to primary problem/nursing priority.
11.Identify labs, if they are high, low, WNL, as well as how the lab is trending.
12.Identify most relevant abnormal lab values. Why are they relevant? What nursing assessments/interventions are required?
13.Identify what radiology/diagnostic results are relevant. Describe the clinical significance of the diagnostic results to the nurse.
14.Describe the primary problem that your patient is presenting with.
15.Describe what nursing priority will guide your plan of care.
16.Describe what interventions with you initiate based on this priority (including nursing interventions, rationale, and expected outcomes).
17.Describe what body system(s) you will assess based on priority concern.
18.Describe the worst possible/ most likely complication to anticipate.
19.Describe what nursing assessments you will need to initiate to identify the complication if it develops.

1. Describe what is the most important discharge/education priority you will reinforce with their medical condition to prevent future readmissions with the same problem.
2. Describe some practical wats you as the nurse can assess the effectiveness of your teaching with this patient.
3. Describe what modifications you will need to make related to your teaching methods based on the patients age, culture, and level of health literacy.

1. Describe what the patient is most likely experiencing/feeling right now in this situation.
2. Describe what you can do to engage yourself with the patient’s experience, and show that he/she matters to you as a person.

1. Describe how you can assess the effectiveness of communication with the patient and family.
2. Describe how you can ensure that your patient is an active partner while under your care and promote self-care upon discharge.
3. Teamwork & Collaboration: Describe what you can do to facilitate safe and effective report to the physician or oncoming nurse.

Describe what electronic data bases are available in your clinical setting that would be a resource if needed to obtain information on a medication that you have never given before or illness/surgery that you have never seen before.

1. Describe what you would as a nurse if you gave the dose of medication because of a similarity in the label provided by pharmacy or another drug.
2. Evidence Based Practice: Describe as a new nurse, what resources could you utilize to provide current, evidence based and individualized care planning based on the needs of the patient.