Clinical Judgment and Reasoning

Running head: CLINICAL JUDGMENT AND REASONING
Clinical judgment and reasoning
Name of the student:
Name of the University:
Author’s note

1CLINICAL JUDGMENT AND REASONING
Table of Contents
Introduction:....................................................................................................................................2
Sequencing of proposed assessment: 300 words approx.................................................................2
Process for informing proposed assessment:...................................................................................3
Analysis of findings in relation to the health and clinical assessment:...........................................4
Evaluation of results: 300 words approx.........................................................................................6
Plan of care:.....................................................................................................................................8
Reference:......................................................................................................................................12

2CLINICAL JUDGMENT AND REASONING
Introduction:
Clinical reasoning is an important skill in nursing practice to engage in safe and effective
care. It is the process of critical thinking and decision making that supports the nurse to engage
in comprehensive health assessment of patient, identify potential problem in patient and develop
nursing care plan accordingly (Carvalho, Oliveira-Kumakura and Morais, 2017). This report
discusses the process of focused health assessment of a patient by the analysis of the case
scenario of Lucy, a 32 year old woman with symptom of asthma. The report also provides
detailed plan of care for patients based on analysis of clinical assessment findings.
Sequencing of proposed assessment: 300 words approx
Lucy is a patient who is suffering from asthma since childhood. Although her asthma is
well-controlled by the daily intake of beclomethasone, however current issues for patient is that
she has become dyspnoeic and suffering from respiratory issues. To engage in more focused
health assessment, the proposed sequence is to first consider the patient situation and her context
and then collect all vital cues that can help in assessment of client. To gain an understanding
about patient situation, the background of Lucy and people surrounding her will be assessed.
Knowing about patient’s background and the people surrounding them is important to gain idea
about risk factors of disease. It may also inform about medical history of patient, the role of
culture or social life in the diagnosis of disease and changes in factors overtime resulting in
present clinical condition (Forbes and Watt 2015).
In addition, to collect cues related to patient condition, the plan is to first collect data
related to medical history, social history, family history and medication history of patient and

3CLINICAL JUDGMENT AND REASONING
then engage in clinical assessment of patient as per the signs and assessment of patient. This
would help to process the patient information and prioritize care for patient (Brown et al. 2017).
For example, as Lucy is a patient with asthma from childhood, reviewing family history is
important to understand the reason behind the cause of disease. Secondly, her social life needs to
evaluate to detect environment cause of asthma and presenting issues in patient. As Lucy was
suffering from symptom of dyspnea, wheezing cough and chest tightness, the sequence for
clinical assessment is to first conduct vital sign assessment of patient and then engage in
respiratory assessment. Vital sign assessment like monitoring of BP, pulse, heart beat and
oxygen saturation level is necessary to detect signs and severity of breathing difficulty. Vital sign
assessment is also important as all the vital signs are associated with the pathophysiology of
asthma. In addition, respiratory assessment of Lucy will be done by means of auscultation of
chest and assessment of breathing rate in patient. Hence, respiratory assessment is necessary for
Joel to monitor severity of asthma symptoms (Aaron et al. 2017). Lastly, review of patient chart
is necessary to identify medications taken by patient and the impact of medication on presenting
sign and symptoms. On the whole, the above sequence of assessment can help to process the
information and understand the severity of patient’s health condition.
Process for informing proposed assessment:
The data related to health history is an important element of patient focused health
assessment as it gives idea about past illness, surgery or any surgical complication in patient. The
data related to patient history supports nurse or other staff to gain better understanding about
patient’s problem and the complexity surrounding diseases. It helps in proper identification of
care priorities and enables the delivery of high quality care (Fawcett and Rhynas 2012). To
collect information related to patient history, having patient-centered communication skill is