This Journal Guide is intended to help you critically analyze your application of head-to-toe assessment skills in an adult acute care setting. Use the guide to help you tell the story of your patient and the concept chosen.
This journal will be a narrative, or a story, that helps you focus on what you Noticed, Interpreted the information, how you Responded and your Reflection on the assessment.
This guide provides you with a way of thinking about care that supports the development of your clinical judgment. Although there are many ways of organizing your thinking about patient care and professional nursing practice, Tanner’s (2006) Clinical Judgment Model provides the framework for the questions in this study guide. Your professional development is further supported with feedback from faculty.
Questions to address in Post Conference and in the Clinical Judgment Reflective Journal:
I. Noticing (Assessment): – What did you observe, assess, what object/subjective data did you collect?
1. What did you initially notice about the patient? What do you anticipate is the patient’s problem? What concepts did you notice affected this patient?
2. Describe what you noticed as you spent more time with the patient and/or family. Where your initial thoughts/findings? Are they the same after you completed a more thorough assessment?
II. Interpreting (Diagnosis and Planning):
1. Describe what you thought about the patient (e.g., disease causes, potential resolutions, patterns you noticed). What was the most important data you found to determine the patient’s primary problem (Concept)?
2. What other information (e.g. assessment data, evidence) did you decide you needed as you considered the patient and the patient’s problem? – Did you identify any patterns?
III. Responding (Intervention):
1. After considering the patient and his/her problems, what was your nursing response?
2. Describe stresses you experienced as you assessed the patient or others involved
with the patient.
A. Reflection-in-Action (Evaluation):
1. What happened? What interventions did you provide for your patient? How did the patient, family, and/or staff respond? How are your intervention individualized to you patient?
2. What did you do next? What will you evaluate to know if your intervention were effective? What did you do if your interventions were not effective?
B. Reflection-on-Action (Evaluation):
1. Describe two ways your nursing assessment skills expanded during this experience.
2. Describe two things you learned about the concept/problem that you didn’t know before.
3. Name 2 things you might do differently when you do your next head-to-toe assessment.
You are to write a two-page, single spaced journal using correct spelling and grammar. Write a minimum of three complete sentences per paragraph. Use a 12 font, ½ inch margins.
Tulsa Community College
Career Mobility II Medical/Surgical
Clinical Judgment Rubric Scoring Sheet
Student Name: ________________________ Student TCC ID: _______________________
Clinical Course & Semester_______________________________________
Faculty Name: ___________________________ Date: ________________
Criteria: Grade Earned Faculty Notes
1. Noticed about patient, what is the key problem
2. What were your initial thoughts and how did they stay the same/change after further assessment? S
1. Described your thoughts r/t the patients primary problem
2. What additional data did you need to obtain? S
1. What care did you provide for the patient?
2. Described Stresses YOU experienced (not your patient) in providing care today. S
1. What happened? What interventions did you provide?
2. How did you evaluate your care and what did you do if it was not effective? S
1. Described 2 ways skills expanded
2. Named 2 things you would do differently
3. Describe 2 things you learned about the patient’s problem you didn’t know before? S
1. Two page single spaced
2. 12 font, ½ inch margins
3. Correct grammar and spelling
4. Submitted per faculty instructions
5. Complete sentences S
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