Level II Clinical Reasoning Worksheet Winter 2023

Clinical Reasoning Worksheet (CRW) – In the Hospital

Student Name: _____Group #_______________________ Clinical Week: ___1____

Complete in 10pt font, single spaced, bulleted summarized format; Remove prompters below if space is needed;
CRW not to exceed 8-page maximum

Preparing for Professional Practice

Knowing the Case or Patient Population
What do I know (or need to know) about this patient population?
 What does the diagnosis mean? What is the underlying pathophysiology?
 How do patients with this problem/issue typically present (signs, symptoms, emotional responses,
difficulties, diagnostic test results)? What is the typical / usual clinical course?
 What types of treatments (including medications) are used and why?
 What is the nursing role in caring for patients with this problem / health challenge? What types of
assessment, communication, and psychomotor skills will I likely need to provide safe and effective care
for my patient? What are the treatment priorities and why?

During the Professional Practice Experience

Knowing the Individual . . .
As a Person
What is my patient’s story (narrative)? How do (or might) my patient’s past experiences with health & illness
influence his/her responses to the pathophysiology, treatment, and care? Are there other factors affecting my
patient’s health or response to care (i.e., age, social context, spirituality, personal preferences etc.)?

As a Patient
What makes my patient different from or the same as the “typical” cases? What’s the “normal” (i.e., baseline)
for my patient?

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Level II Clinical Reasoning Worksheet Winter 2023

Noticing – Gathering Cues & Information

You need to gather data/cues information from a wide variety of areas in order to thoroughly
determine the main issues that are affecting your patient. Look for the following information:
Chart Data
Admission note, medical history, report, progress notes (various members of health care team)

Treatment Plan

Medication record, code status, treatments (IV, positioning, oxygen, diet, activity, dressings)

Treatment Order Nurse’s role

Code status
IV
Oxygen
Diet
Activity
Positioning
Other:

Medication: Dose: Administratio Indications: Pharmakokinetics: Nursing

Is this a safe n route: considerations (e.g.
and side effects, nursing
therapeutic care)
dose?

Lab & Diagnostic Reports

What do these findings mean for this patient?

Diagnostic: Why is this diagnostic What is Mrs. Adams’s Interpretation: What is the nurse’s
done? result? What does the role?
result mean?

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Level II Clinical Reasoning Worksheet Winter 2023

Cues from my Patient

Patient’s perception of the situation (concerns, fears, hopes, expectations, etc.); my own observations and
intuition about the patient’s needs

My Assessments (initial head to toe assessment; ongoing assessments during clinical shift)

Look at Head to Toe Assessment Day 1:

What do you notice? Interpreting: What’s expected? What’s

unexpected? Has anything changed from
admission or baseline? Is anything a priority?
Bedside:
General:
Vital signs
Neuro:
Resp:
CVS/PVS:
Abdo:
Skin:
GU:
MSK/activity:

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Level II Clinical Reasoning Worksheet Winter 2023

Interpreting – Recognizing Patterns & Interpreting Data

Key Issues Rationale Priority Level
What are the most important issues for your patient? What are your What subjective and objective What needs to be attended
nursing diagnoses? List at least 3 issues/nursing diagnoses. cues/assessments indicate that to first and why? Provide
these issues exist? support for your ranking.

Responding – Determining a Course of Action

Goals/Outcomes Nursing Actions/Interventions Rationale
What are the desired What interventions would address the identified issue? List 3-4 What are the reasons for my decisions and
short and long term interventions for each nursing diagnosis/issue. actions? How does literature/evidence
goals? support these actions?
(Use SMART goals)
Priority Issue/Nursing Diagnosis #1:

Goal: Interventions: Rationale:

1.

2.

3.

4.

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Level II Clinical Reasoning Worksheet Winter 2023

Priority Issue/Nursing Diagnosis #2:

Goal: Interventions: Rationale:

1.

2.

3.

4.

Priority Issue/Nursing Diagnosis #3:

Goal: Interventions: Rationale:

1.

2.

3.

4.

References:

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Level II Clinical Reasoning Worksheet Winter 2023

After the Professional Practice Experience (1/2 page / 1 paragraph max.)

Reflection – On Action and Clinical Learning
How did the nursing care plan meet my patient’s needs? Were outcomes/goals achieved? What were my
strengths today? What areas could I work on? What did I learn from my patient today? What did I learn about
myself? If I could repeat this day in clinical I would…

References
Gillespie, M. (2010). Using the Situated Clinical Decision-Making framework to guide analysis of nurses'
clinical decision-making. Nurse Education in Practice, 10, 333-340
doi:10.1016/j.nepr2010.02.003) 

Tanner, C. A., Benner, P., Chesla, C., & Gordon, D. R. (1993). The phenomenology of knowing the
patient. Image: Journal of Nursing Scholarship, 25, 273-280.

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