Name_________________________ Clinical Reasoning Map Date______________
Critical Thinking and Clinical Reasoning Map
Admit Date: Age: Gender:
Allergies: Admit Dx: Code Status:
Activity: Diet:
Vital Signs 0800 1200 1600
T
HR
RR
BP
O2
In the event an assessment area below is not appropriate simply put NA in the box and note in the nurse’s note
Height: Living situation: Immunization Status:
Weight:
OFC:
Past Medical/Surgical History:
Summary of developmental level (consider is this child age appropriate, note any delays, analyze cues that indicate appropriateness or
inappropriateness):
Neuro: Cardiac: Respiratory:
Name_________________________ Clinical Reasoning Map Date______________
A & O x ________ / Confused: Pink / Pale / Warm / Cool / Dry / Diaphoretic / O2 @ __________L NC / Mask / NRB / Room
_________________________ PERRLA / Other_____________ Cap Refill time: ________ air / Other ____________
Cooperative / Clear speech / Other: S1 / S2 / S3 / S4 / FIO2: ________ L: ________
__________________________________________
_ Activity: Up ad lib / 1 or 2 person assist / Bed rest / Tele / Rhythm: ________________ Auscultation: Breath Sounds:
BSC / Walker / Cane / Bed Alarm / Fall Risk / Reg / Irreg: L: Clear / Diminished / Wheezing / Crackles /
Neuro ✓ Murmur: ___________________ Coarse
Edema: None / Gen / R L / Bilateral Trace 1+ 2+ R: Clear / Diminished / Wheezing / Crackles /
3+ Pitting / Non-pitting Coarse
Location____________ Increased WOB: Yes / No
Pulses: Cough: Yes / No
Radial: Strong / Weak / Not palpated/ Doppler / Productive / Non-productive / NA
equal / _____ Treatments: IS / SVN / Suction:
Pedal: Radial pulses: Strong / Weak / Not
palpated/ Doppler / equal / _____
GI: GU: M/S:
BS: Hypo / Active / Hyper Assess: Nausea / Vomiting: Voiding / Foley / Incontinence / Anuria Clear / Upper Strength _____/5 in RUE / RLE
______ Last BM: _________ Consistency/ Color: Cloudy / Yellow / Amber / Bloody / Other: Lower Strength _____/5 in LUE / LLE
_________________ Abd: Soft / Tense / Firm / Non ______________ BR / Urinal / BSC / Bedpan /
tender / Tender / Distended External Cath Weak/ Numb / Decreased ROM / Other:
Gait: _____
Skin/Wounds IV: Precautions:
Description: Site: _____ Fall / Bleed / Contact / Airborne / Droplet /
Protective
Gauge: _____
Saline-locked: Yes / No
Name_________________________ Clinical Reasoning Map Date______________
Location: Maintenance Fluid: _____________
Rate: ________
Date placed: _____
S&S of infiltration or phlebitis:
Yes / No
Action: ______
Name_________________________ Clinical Reasoning Map Date______________
Complete Lab section if appropriate. In the event your patient does not have labs simply note that in your
nurse’s note.
Lab Result Date/Time
PT/INR
PTT
Blood Glucose 1. ______ 1. _____
2. _____ 2. _____
3. ______ 3. _____
4. ______ 4. _____
ABG
pH
PaCO2
HCO3
Diagnostic Tests:
Name_________________________ Clinical Reasoning Map Date______________
Pathophysiology (In your own words):
Complications/Potential Complications (Risk Reduction):
Psychosocial Concerns (Psychosocial Integrity):
Name_________________________ Clinical Reasoning Map Date______________
Recognizing Cues: Assessment findings that Prioritize Hypotheses: These are your Nursing Take Action: These are your interventions. What
warrant further investigation Problem Statements. What do you think is the highest will you do to help improve your client’s condition or
(VS/Subj./Obj./Labs/Diagnostics/Risk priority? What is it related to? Is it an actual problem or prevent further deterioration? (Basic care & Comfort,
Factors/Psychosocial): Safety and infection control, Pharmacological therapies,
a risk problem?
Education, Health promotion, and management of
1.
care):
2.
3.
4.
5.
6. Generate Solutions: Planning and goal setting.
What do you want as an outcome for your client? Goals
7. should be SMART goals.
8.
9.
10.
**May have more than 10 cues
Analyze Cues: What do you think might be going Evaluate Outcomes: Did your actions result in the desired outcome for your client?
on with the client? What does it mean? This is where
you analyze the data you collected:
Name_________________________ Clinical Reasoning Map Date______________
Medication Name Patient’s Dose, Why is patient Nursing Side effects and Patient Teaching
(Generic) and Drug Route, and receiving this considerations (labs, Major adverse effects
class Frequency medication? assessment, etc.)
Name_________________________ Clinical Reasoning Map Date______________
Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care):
Summary Report to Healthcare Provider (SBAR Format):
S-
B-
A-
R-
