NSG 336 -MSI Clinical Reasoning Form

Instructions for Clinical Reasoning Form

Medical-Surgical Nursing NSG 336

Students will need to spend approximately 2 hours of preparation time prior to attending their clinical experience. The goal of the clinical reasoning form is to organize your thoughts and apply the nursing process. You may use other notes or formats while preparing for your patient assignment. Clinical and Post Conference activities will focus on your verbal and/or written presentation of the clinical reasoning form contents. You may be selected to present any section of the materials as outlined by your clinical faculty. If your post conference participation requires a more in-depth approach, your clinical faculty may request that the student submit written work for certain sections of the clinical reasoning form for feedback. The expected outcome is to be able to critically reason while becoming comfortable preparing for clinical and to verbally present the contents of the clinical reasoning form. However, at times your clinical instructor may require you to turn in written materials in order to further evaluate your progress in applying the nursing process. Any requirement to turn in written work is based on each individual student’s progress and evaluation of their performance.

Please refer to the highlighted sections of the clinical reasoning form for further detailed information on each area.

Med Surgical I Critical Reasoning Form

Due: As directed per individual performance by clinical faculty

Student Name:

Date:

Biographical Data:

Patient Initials: Age: Gender: Marital Status: Race:

Occupation (Previous Work):

Cultural Considerations:

Spiritual Assessment and Needs:

Erickson Development Stage (Identify stage, support your answer and explain how it impacts health):

This section will be covered verbally in clinical and or post conference.

Admit Date:

(explain how their illness presented and brought them to the hospital):

Admitting or Primary Medical Diagnosis: Explain the medical diagnosis of your patient in your own words. Correlate the medical diagnosis’s patho, assessment findings, labs, tests, treatments/meds, with your client’s presentation and treatment plan. IF they do not correlate, explain why

Secondary MEDICAL Diagnosis/Chronic Diseases: Explain briefly all the secondary diagnoses that may impact the primary diagnosis and medications the patient are taking for these medical conditions. There may be more than 3, so please document more following this format if needed.

Secondary Diagnose Description:

How they may impact present diagnosis:

Medications(just the names):

Secondary Diagnoses Description:

How they may impact present diagnosis:

Medications(just the names):

Secondary Diagnoses Description:

How they may impact present diagnosis:

Medications(just the names):

NSG 336 -MSI Clinical Reasoning Form

Interprofessional Team Care Plan (explain the goals & interventions that other healthcare professionals are providing for the client such as RT, PT, OT, ST, etc):

This section will be covered verbally in clinical and/or post conference.

Discharge Teaching/Planning: What does your patient and his/her family (or ECF) need to know to avoid readmission?

This section will be covered verbally in clinical and/or post conference.

List a Health Promotion Plan (What can you teach that is age, gender, and/or condition specific to promote health in your patient? Think about home safety, med safety, and specific disease prevention screening the client would discuss with their primary care physician. .)

Example: 58 year old female needs a yearly mammogram, yearly pap smear, and colonoscopy every 10 years, FBS, and annual physical

This section will be covered verbally in clinical and/or post conference.

PLAN FOR THE DAY

Organize your task list for the day.
Highlight what interventions you want to address for the day.

STUDENT MAY COMPLETE FOR THEIR OWN REFERENCE

Assessment Data

Identify assessment data that impacts that client’s plan of care

Complete during clinical for faculty to review during clinical and/or post conference

Vitals:

Overall Appearance:

Neuro:

HEENT:

Respiratory:

Cardiac:

Perfusion:

Abdominal:

Renal:

Musculoskeletal

:Gait:

NSG 336 -MSI Clinical Reasoning Form

Student may use this format as a resource. Content will be covered during clinical and/or post conference.

Students may be asked to complete the format as written work by individual clinical faculty in order to further evaluate their performance of applying the nursing process.

Nursing Diagnosis #1-Refer to your Ackley book, Lewis book, and Basics book

**********Maslow’s Hierarchy of Needs listing1. Physiological 2. Safety 3. Belonging-Love 4. Self esteem 5. Self-Actualization ***********

Negative Assessment Data also referred as “cluster cues or defining characteristic of nursing diagnosis” needs to be listed here :

Why did you prioritize this nursing diagnosis #1? explain your thinking (note Maslow’s Hierarchy of needs)

Nursing Diagnosis #1 NANDA Label: Related to: Evidenced by:

Outcome/Goal (must be measurable, have time frame, and verify resolution of the NANDA Label) Ex: Client will have improved mobility evidenced by walking 20 feet with walker by discharge. This client had the nursing diagnosis impaired mobility related to left knee tissue trauma (surgical incision) evidenced by unable to bear weight due to rating pain above

***************Evidenced Based Interventions: only 1 assessment intervention is permitted: monitor is an assessment*******************

Interventions must be specific, pertinent to the goal, and should include who, what, where, how much, and why is the book reviewed rationale.

#1 Intervention

#1 Rationale (book reviewed physiological principles)

#2 Intervention

#2 Rationale (book reviewed physiological principles)

#3 Intervention

#3 Rationale (book reviewed physiological principles)

#4 Intervention

#4 Rationale (book reviewed physiological principles)

Evaluation of meeting outcome’s measurable criteria: (how will plan be adapted if outcome/ goal not met)

Nursing Diagnosis #2-Refer to your Ackley book, Lewis book, and Basics book

**********Maslow’s Hierarchy of Needs listing1. Physiological 2. Safety 3. Belonging-Love 4. Self esteem 5. Self-Actualization ***********

Negative Assessment Data also referred as “cluster cues or defining characteristic of nursing diagnosis” needs to be listed here :

Why did you prioritize this nursing diagnosis #2? explain your thinking (note Maslow’s Hierarchy of needs)

Nursing Diagnosis #2 NANDA Label: Related to: Evidenced by:

***************Evidenced Based Interventions: only 1 assessment intervention is permitted: monitor is an assessment*******************

Interventions must be specific, pertinent to the goal, and should include who, what, where, how much, and why is the book reviewed rationale.

#1 Intervention

#1 Rationale (book reviewed physiological principles)

#2 Intervention

#2 Rationale (book reviewed physiological principles)

#3 Intervention

#3 Rationale (book reviewed physiological principles)

#4 Intervention

#4 Rationale (book reviewed physiological principles)

Evaluation of meeting outcome’s measurable criteria: (how will plan be adapted if outcome/ goal not met)

Students may use this as a tool to document data. Information will be presented/discussed during clinical and/or post conference activities. Students may be requested to provide written completion of the materials in order to evaluate their performance in this area.

Test	*Normal	Results w/Dates	Why was this test ordered ? (What are we looking for or monitoring ?)	If abnormal, what caused the result ?	Why are we concerned about the abnormal result ? (How will it affect the body ?)
CBC
WBC	4.5-10.8
RBC	4.5-6.1
HGB	13-18
HCT	37-52
MCH	27-31
MCHC	33-36
RDW	11.5-14.5
Platelets	150-350
MPV	7.4-10.4
Neuts	1.6-8.3
Lymphs	0.8-4.7
Monos	< 1.5
Eos	< 0.4
Baso	< 0.2

Test	*Normal	Results w/Dates	Why was this test ordered ? (What are we looking for or monitoring ?)	If abnormal, what caused the result ?	Why are we concerned about the abnormal result ? (How will it affect the body ?)
ABG
pH	7.35-7.45
pCO₂	35-45
pO₂	80-105
HCO₃	22-26
Total CO2	23-27
BE	0-3
UA
Color/Clarity	Yellow/ Clear
pH	5-8
Specific Gravity	1.002-1.035
Protein	Negative
Glucose	Negative
Ketones	Negative
Occult Blood	Negative
Nitrite	Negative
Bilirubin	Negative
Urobilinogen	0-1
WBC	Negative
Bacteria	Negative
Hyaline Casts	Negative

Test	*Normal	Results w/Dates	Why was this test ordered ? (What are we looking for or monitoring ?)	If abnormal, what caused the result ?	Why are we concerned about the abnormal result ? (How will it affect the body ?)
BMP
Sodium	135-147
Potassium	3.5-5.0
Chloride	98-107
CO₂	22-29
Anion Gap	8-16
Osmol	275-295
Creatinine	0.7-1.3
BUN	8-26
GFR	> 60
Glucose	70-109
Calcium	8.4-10.2
Magnesium	1.6-2.6
Others
Total Bilirubin	0.2-1.2
AST	5-35
ALT	0-55
Alk Phos	45-115
CK	30-200
CKMB	0-7.2
Troponin I	<0.028
BNP	0-100
Test	*Normal	Results w/Dates	Why was this test ordered ? (What are we looking for or monitoring ?)	If abnormal, what caused the result ?	Why are we concerned about the abnormal result ? (How will it affect the body ?)
Others
Total Protein	6.0-8.3
Albumin	3.4-4.9
Total Cholesterol	<200
Triglyceride	0-149
HDL	> 39
LDL	<100
C-Reactive Protein	0-0.8
Phosphorus	2.5-4.5
PT (sec)	11.6-14.3
INR	0.9-1.1
PTT (sec)	22-35
TSH	0.5-8.9
T₃	1.08-3.14
T₄	4.6-12

Test	*Normal	Results w/Dates	Why was this test ordered ? (What are we looking for or monitoring ?)	If abnormal, what caused the result ?
Drug Levels
Culture Results (list where specimen was taken and results)
Diagnostic Tests (Xrays, CT, MRI, biopsies, dopplers, cardiac caths)

NSG 336 -MSI Clinical Reasoning Form

The following pages are the Medication Section. The SBAR Page must be completed and given to the Floor RN with an oral report prior leaving the floor.
Students may use this as a tool to document their medication information. Students will need to follow their individual faculty instructions

for medication content review for their clinical assignments. Students will need to be knowledgeable about their patient’s medications for

each clinical assignment. Students should be aware of the scheduled medications during their clinical hours and also prn medications

taken within the last 24 hours.

Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/what teaching needs to be done)




Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)

Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)

	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)



Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/what teaching needs to be done)

Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)




Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)

	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)

KINDLY ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER

Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/what teaching needs to be done)




Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)
	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)

Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)

	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)


Drug/Dose/Route/Frequency	Classification: Therapeutic:	Indications/Action: (How the medicine works in the body & why they are receiving the medication)

	Pharmacologic:

Adverse Effects:(Complications to monitor during clinical)		Nsg Implications:(What to assess in client/need to know prior to giving/ what teaching needs to be done)

Each student should utilize this sheet for practicing and organizing their hand-off procedure at the end of their clinical shift.

HAND OFF COMMUNICATION TOOL

FOR SHIFT-TO-SHIFT REPORT

Situation: Name______________________________________Age______Date of admission__________

Diagnosis__________________________________________________________________________________________

Physician / Consults / Covering physician_________________________________________________________________

Procedures________________________________________________________________________________________

Response to treatment_______________________________________________________________________________

Length of stay on unit________________________________________________________________________________

Background: Advance Directive ??Yes ??No ??Hard copy in chart

Code status_______________________________________ Isolation status____________________________________

Meds / Allergies____________________________________ Med Rec completion_______________________________

Central lines / IV sites_______________________________ IVs / drips_______________________________________

Medical hx / Procedures_____________________________ Psyco/social concerns / Families______________________

Influenza vaccine indicated___________________________ Pneumonia vaccine indicated________________________

Assessment:

Vital signs________________________________________ Mental Status_____________________________________

Pain_____________________________________________ Activity level______________________________________

Telemetry_________________________________________Nutritional status__________________________________

Oxygen__________________________________________ Fall risk_________________________________________

Accucheck________________________________________ Skin alert________________________________________

Lab results________________________________________ Last BM / I&O____________________________________

Dressings / wounds_________________________________ Drains__________________________________________

Special needs (hearing/vision/language/appliances) _______________

Recommendations: Plan of care updated__________

Discharge plan_____________________________________ Pt. teaching / Education_____________________________

Anticipated changes________________________________ Evaluate need to d/c lines, Foley, etc.__________________

NSG 336 -MSI Clinical Reasoning Form

NSG 336 -MSI Clinical Reasoning Form

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