Clinical Worksheet

Clinical Judgement – This tool outlines a linear path to help the novice nurse begin forming their aptitude for clinical reasoning and critical thinking that ultimately contributes to sound clinical
judgements. However, it is essential to appreciate that clinical judgement is NOT linear and does not happen as a singular event occurring only at the beginning of the shift. Rather clinical
judgements are made in a dynamic and ongoing process wherein the nurse (or student nurse) is continuously assessing for cues, analyzing their meaning, prioritizing actual or potential problems,
generating solutions, taking action, evaluating the outcomes of those actions and adjusting care based on patient status. The following elements of this worksheet should be completed soon after
initial nursing assessment, morning medication administration, and routine morning cares. Subsequently, the students nurse should be disciplined to an ongoing and cyclical nature of the clinical
judgement process throughout the clinical day and routinely informing their faculty of observations, interpretations, proposed nursing interventions, and evaluations of those outcomes.
Communication is key to the faculty’s ability to access your performance over time and our growing competence in nursing practice.
Step 1: Recognize Cues Step 2: Analyze Cues
Using all the patient data (both subjective and objective gathered from history and physical Now interpret the cues you’ve identified in your patient. Relate the patient findings to actual or
assessment and lab/diagnostic findings) list those that are most important to follow up and possible disease processes.
important to your patient care planning this shift. Include cues/trends in patient status that given
the patient’s background and current status, that you will want to be sure to watch for and be Cue or Set of Cues Corresponding actual or potential
sure to recognize throughout the shift. problem/s (disease/s)
IV antibiotic (meropenem/vancomycin)
IV antibiotic (meropenem/vancomycin) Increased neutrophils, WBC, BUN Infection
Increased neutrophils, WBC, BUN Vital signs
Decreased GFR and MAP LR 75 mL/hr
Eliquis for AFIB Norepinephrine Decreased Cardiac Output
Supplemental O2 (2-3 L) Decreased GFR and MAP
LR 75 mL/hr Eliquis for AFIB
Norepinephrine Increased RR
HOB > 30° Lasix
Increased RR Metoprolol
Vital signs HOB > 30°
Lasix Supplemental O2 (2-3 L) Impaired gas exchange
Metoprolol Increased RR
Step 3: Prioritize Hypothesis
Bits of information gained from cues must be synthesized by the nurse to make meaning of the information and to begin establishing a prioritized plan for care for the patient. Considering the cues
analyzed, list (in rank order) the patient’s priority problem/s (actual or potential [what might the patient be at most risk of]) with explanation for your prioritization.
Highest Risk for Developing: Evidenced By: Rationale:
Increased BUN I chose this for my number one pick due to we are currently treating her
Increased WBC infection. Patient is trending in the correct direction but is not at baseline
Infection Increased neutrophils yet.
IV antibiotics
Decrease GFR Her CO was decreased shown by the MAP. She has a hx of AFIb, but not
Decreased Cardiac Output Increase RR currently in that rhythm. We are currently treating her low CO with
Decrease MAP norepinephrine (paused), Eliquis and LR (paused). I think since her
LR 75 mL/hr pressures are increased since the beginning of shift that infection is more
Eliquis important since it is ongoing.
Norepinephrine
Metoprolol
Lasix

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2-3 L of O2 O2 drops at night due to her sleep apnea. It is important to help treat but
Impaired gas exchange HOB > 30 ° not priority.
Increased RR

Step 4: Generate Solutions

Based on the priority hypotheses, identify your course of nursing interventions for each and note for the associated timeline for completion [emergent, urgent, essential, per timeline of order],
Highest Actual or Potential Patient Problem Nursing Intervention/s aimed to address the patient problem – indicate if the intervention is emergent, urgent, essential (what
timeframe does it need to be completed within)
IV antibiotics (meropenem/vancomycin)
Lab draws
Infection Deep breathing coughing
LR running at 75 mL per hour
Decreased Cardiac Output Eliquis
Norepinephrine: on standby
Metoprolol
Lasix
2-3 L of O2 when O2 stats decrease
Impaired gas exchange HOB > 30°
Deep breathing and coughing
Up in chair during the day
Walking

Knowing what interventions are contraindicated is often as important as knowing what interventions are indicated. What nursing interventions would be contraindicated, and therefore avoided, for
your patient?

Potential medication contraindications. Meropenem and vancomycin are not contraindicated with lactated ringer if used with a Y-site.

Expected outcomes: Cues from assessment data can help us identify patient health problems as well as help us monitor effectiveness of nursing intervention. In this section, write SMART
(specific, measurable, attainable, realistic, time-bound) goals for each of your patient problems that require nursing interventions. These goals should include which patient cues would suggest
your interventions were successful. This will help you prioritize follow-up assessments and determine the potential need for revision of nursing interventions.
Example: Patient will demonstrate improved cardiac output by achieving a systolic blood pressure >90mm HG or a MAP >65mm HG upon completion of the
prescribed 1L fluid bolus.
Patient’s will demonstrate no more signs or symptoms of infection resulting by her lab values being in the normal range by tomorrow mornings labs.

Patient will demonstrate increased cardiac output by having a MAP > 65 all day without the use of norepinephrine.

Patient will demonstrate increased gas exchange by deep breathing and coughing, and without the need of supplemental O2 (SPO2 > 93%) by the end of the day.

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Care Plan Conference with Clinical Instructor – this is a good point in time to provide your faculty person an SBAR of your patient. Important findings from history,
physical exam, vital signs, labs, diagnostics, and your proposed plan of care (Step 4 above). You should be prepared to:
1. share what cues you noticed from the assessment, vitals, labs, diagnostics, what you think they mean, and what is happening to explain these findings
2. discuss how current treatments (nursing and medical) address the priority problems, and concerns you have about the current plan of care
3. offer how you plan to respond to findings (including any collaboration/consultation needed, what you can delegate and to who, what follow up has been
done or is needed, safety needs

Priority Problem Step 5: Take Action Step 6: Evaluate Outcomes

Highest Actual or Potential
Patient Problem
Infection
Identify the patient care goal/s associated to the actual or potential problem listed Were the interventions effective? Were goals met, not met, partially met with
to the left. Document all nursing interventions planed/implemented that are aimed revision. Did the patient’s condition improve/decline/remain unchanged?
to help reach the identified goal. What findings are you basing this determination?
Hung antibiotics (meropenem/vancomycin)
Increased BUN, creatinine/BUN ratio, decreased GFR Not sure due to not knowing the lab values the following day.
Vital signs
Cough/deep breathe Incentive spirometer use has been good all day.
Use of incentive spirometer

Decreased cardiac output Gave Lasix, metoprolol, Eliquis Interventions were effective. Goal was met. Map has been above 65 all day
Stopped the LR 75 mL/hr without the use of norepinephrine.
Vital sign evaluation

Impaired Gas Exchange
When O2 needed – 2 L Not met. Patient on supplemental O2 all day.
HOB > 30°
Walks
Deep breathing/coughing
Incentive spirometer
Sat in chair