4 “Real World” Examples of Using Clinical Judgement to Figure Out What to Do First as a Nurse [master post]

clinical judgement reasoning nursing

Ever wonder what a nursing care plan is good for except kindling for your fire?


Me too.


That is why I am super excited to share this with the NRSNG family.


Developing sound clinical judgement and critical thinking can be one of the most complex yet vital skills a nurse must develop.


Welcome to the post about how to put into action your nursing care plan and prioritize your tasks to use clinical judgement in a way that brings your care plan actions and critical thinking together like chicken and waffles.


4 “Real World” Examples of Using Clinical Judgement in Nursing Care

We have written extensively on nursing care plans and critical thinking here.  This post is designed to give you a real life taste of nursing care plans and how clinical reasoning can help you in caring for a patient.


Nursing Care Plan and Clinical Judgement Example 1: Sepsis

sepsis critical thinking


Patient brought to the ED via EMS for altered mental status. The patient is a 72-year-old female with a baseline orientation of person and place.


The son called 911 today after checking up on his mother and finding her sleeping in the bathtub. Per the son, “I tried to get her out of the bathtub but she didn’t recognize me. She felt pretty hot too, like she has a fever. She kept saying. ‘Go away. I don’t know you.’” The son reports that she normally answers the phone but when she didn’t answer today he went to check on her and he found her in the bathtub acting strangely.


Head-to-toe assessment:

The patient is currently mumbling to herself nonsensical words, doesn’t follow commands, but does answer her name. Facial expressions are symmetrical and pupils are equal round and reactive to light. Patient does not follow commands for eye accommodation to accurately be assessed.


Patient lung sounds are clear bilaterally, chest rise and fall are even, breathing is non-labored although the respirations are 28 breaths per minute.

S1 and S2 are auscultated and peripheral radial pulses are +1 bilaterally and pedal pulses are +1 bilaterally. The cardiac rhythm is sinus tachycardia with the heart rate regular at 120 beats per minute. Capillary refill is 4 second.


Bowel sounds are active and abdomen is soft and non-tender upon palpation in all four quadrants, neither the son nor the patient knows of last bowel movement. The patient is currently incontinent of malodorous urine saturating clothing down to patients socks and shoes.


Skin is hot and dry, tenting turgor noted as well as flaky skin. Mucous membranes are dry and tacky.


Patient has a rectal temperature of 103F and pulse oximetry reading of 94% on room air.


Patient unable to perform active range of motion due to weakness, passive range of motion checked and is within normal limits.


NANDA-I nursing diagnosis:

Fluid volume deficit related to dehydration and septic shock as evidenced by tenting and dry/flaky skin, dry mucous membranes and tachycardia.


Risk for ineffective tissue perfusion related to dehydration and septic shock as evidenced by tenting and dry/flaky skin, dry mucous membranes and tachycardia.


Impaired urinary elimination related to urinary tract infection as evidenced by urinary incontinence and malodorous urine.


Acute confusion related to urinary tract infection and altered mental status as evidenced by nonsensical words and inability to follow commands.


Impaired oral mucous membrane related to dehydration as evidenced by dry, tacky mucous membranes and flaky, tenting skin.


Adult failure to thrive related to self-care deficit, as evidenced by soiled clothing and poor hygiene.


Plan of care:



Find source of infection

Temperature control

Rule out head trauma


Implementing Plan of care:

  1. Fluids, antibiotics, and finding a source of infection is carried out by starting an IV, collecting blood work and straight cathing for urine specimen. Then starting the fluids and antibiotics. (The order of drawing labs BEFORE starting IV antibiotics is vital).
  2. Temperature control will be monitored and treated with rectal Tylenol/Motrin alternation and temperature re-checks every 30 minutes until within normal limits. (Fluids helps bring down body temperature as well)
  3. Ruling out head trauma will be confirmed through a head CT scan.



Nurses to-do list:

What to do first:

Using the ABC’s we look at

1) the airway is patent (for help with airway read THIS)

2) breathing is fast but manageable, symmetrical and oxygen saturation is above 90%. This patient is most likely breathing fast due to being febrile.

3) Circulation is compromised as evidenced by tenting skin turgor, dry mucous membranes, capillary refill is delayed, heart rate is tachycardic, and pulses are present but weak.


This patient is most likely septic from a UTI and evidence based research shows that the quicker you get the client fluids and antibiotics the better the outcome. This is time sensitive so you will need to delegate certain tasks (such as: undressing patient and placing them on the cardiac monitor, starting 2 IVs, obtaining an EKG, getting blood work and a urine sample).


The very first thing that needs to happen, no matter who does it, this patient will need an IV and blood work, including lactic acid and blood cultures. Since blood cultures require two sets from two different sites, start 2 IVs, the larger the gauge the IV the better. Getting blood work is important because it gives us a baseline to measure patient outcomes. You must get blood cultures and urine sample before starting any antibiotics. If possible, getting a lactic acid before administering fluids would be best for the patient but if blood is difficult to obtain it is more important to start the fluid boluses first.


Remember, delegating laboratory specimen collection is appropriate. This patient needs to have their urine collection be a sterile straight cath because the urine culture can help us identify the specific organism causing the infection and it won’t be helpful if it is contaminated.


While others are getting the laboratory testing, starting the IV, and undressing/placing the patient on the monitor, you need to pull the medications (antipyretic, antibiotics, and normal saline fluid boluses) as well as calling CT to get this patient an appointment to get their scan as soon as possible. Give the rectal antipyretic as soon as you are able and start a timer for re-check in one hour of giving the medication, but do not delay IVs, fluids, or CT scan to give this medication. Controlling the patients’ temperature is important but not a priority.


The CT scan is important because the patient was found in the bathtub with altered mental status, she was not witnessed getting into the bath tub (she may have fell and hit her head) but due to age, mentation, and an unknown last well time, the patient needs to have their head scanned to rule out any swelling or bleeding in the brain.


Once an IV has been established, the most important thing to do is start IV fluids, no matter if blood work was obtained or not. This addresses the first concern: Circulation, since airway and breathing are stable.


Next important thing to focus on is CT. If the CT scanner is ready, you take the patient at this time. If the scanner is not ready, focusing on obtaining blood and urine cultures is the priority at this time. Once blood and urine cultures are obtained starting antibiotics is the next priority. If the CT scan did not occur earlier, it needs to happen now. Finally, a temperature re-check and charting can happen at this time.


Providing care to a septic patient will require a high level of stamina and clinical judgement as the patients condition can change quickly and drastically.


The plan of care at this point is waiting for results and determining if the patient needs a 2-hour lactic acid draw or 2-hour troponin draw. Once all results are in the doctor will determine which floor they want this patient to go to and the nurse needs to prepare the patient to be admitted (Updated vitals, all personal property is accounted for and with the patient, any abnormal results be addressed, family updated on plan of care, etc.).


Report to the floor will need to be called and the plan of care needs to be conveyed. For example:

This is a 72-year-old female with altered mental status who was found in her bathtub by her son. She has a urinary tract infection that has gone septic, she has a zero-hour lactic acid of 3 and a 2-hour lactic acid of 2.1, she has received her weight based fluid bolus and is now receiving normal saline at 75 mL/hr. She has received her first dose of antibiotics and needs her second dose. She is alert and oriented to person only, baseline is person and place, she is weak and is on bed rest at this time.

While that sounded like an entire shift’s worth of tasks, realistically the above process is done in less than an hour.



Nursing Care Plan and Clinical Judgement Example 2: Pneumonia

pneumonia case study


A 54-year-old male came into the emergency department complaining of difficulty in breathing, cough and congestion for 3 days. The patient states, “I lose my breath even just going to the bathroom. I start to cough and hack up yellow stuff and I have to sit down to catch my breath.” The patient denies any history of COPD and does not smoke.


Head-to-toe Assessment:

The patient is not using accessory muscles to breath, however, he is using the tripod position and can only say a few words before he is out of breath. Chest rise and fall are symmetrical and respirations are 36 breaths per minute. The patients’ lips are grey and his pulse oximetry is 84%. Patients lung sounds are diminished bilaterally in the lower lobes.


Patient denies chest pain, dizziness, N/V/D, or blood in sputum. Cardiac rate and rhythm are within normal limits, S1 and S2 are auscultated, peripheral radial pulses are +3 bilaterally and capillary refill is less than 3 seconds.


Patient is alert and oriented to person, place, time and situation. Pupils are equal, round, reactive to light and accommodates. Facial expressions are symmetrical and all extremities are active range of motion.


Bowel sounds are active, abdomen is soft and non-tender in all four quadrants, and last bowel movement was today: soft, brown and formed. Patient denies any burning upon urination, discoloration, or frequency.


Patient skin is pink, warm, and dry except for his lips which are grey. Mucous membranes are moist and intact. Skin turgor is within normal limits, no swelling to extremities noted at this time. All other vital signs are within normal limits.


NANDA-I nursing diagnosis:

Ineffective airway clearance related to copious amounts of respiratory secretions secondary to pneumonia as evidenced by shortness of breath, cough, yellow sputum, low pulse oximetry and grey lips.


Ineffective peripheral tissue perfusion related to difficulty in breathing and copious amounts of respiratory secretions secondary to pneumonia as evidenced by low pulse oximetry and grey lips.


Risk for activity intolerance related to difficulty in breathing and low oxygen pulse oximetry secondary to pneumonia as evidenced by shortness of breath upon activity and inability to complete full sentences without losing breath.


Plan of care:

Oxygen (listen to this podcast on O2 therapy)

Breathing treatment

Steroids (listen to this podcast episode on steroids therapy)

Chest X-Ray

Fluids (download this cheatsheet on fluid therapy)


Blood work (learn about blood cultures here)

Sputum collection (learn more about sputum cultures here)


Implementing plan of nursing care plan:

  1. Oxygen, breathing treatment, and sputum collection will be done as a nasal cannula first until the breathing treatment is ready. Then after the breathing treatment, place patient back on nasal cannula. The breathing treatment will loosen up sputum and collection will be able to happen either during or after the treatment.
  2. Fluids, steroids, antibiotics, and blood work will be completed by starting an IV, getting blood work, and then administering medications.
  3. Chest x-ray for difficulty in breathing patients is usually a one view chest x-ray is done portably to the room the patient is in, the nurse will need to call X-Ray to alert them of the need for a chest x-ray.


Nurses to-do list:


What to do first:

Using the ABC’s the first thing that needs to be addressed is airway and breathing. The airway is compromised by copious amounts of secretions and is effecting the patients’ ability to breath.


This patient needs a breathing treatment first, however, that requires getting an order, going to the pixis and pulling the medication. All rooms should be equipped with a nasal cannula and placing the nasal cannula on the patient at 2 L is the number one first thing to do. Next get the breathing treatment and supply the patient with a cup to spit their sputum into.


All rooms need to have their suction equipment ready to go before a patient ever goes into that room, however, do not be caught with your pants down, this is the time to check that the suctioning is functioning properly. Give the suction to the patient and explain how to use it. This patient is alert and oriented times four and all extremities are AROM thus this patient can suction themselves. This addresses the first concern AIRWAY and simultaneously addresses the second concern BREATHING.


As this is happening, delegate getting that patient undressed, in a gown, obtaining an EKG as well as an IV and blood work.


While others are doing the IV, blood work, etc. go to the pixis and pull the steroids and fluids. While doing this call respiratory therapy (RT) and inform them that there is a patient with low oxygen saturation levels, the patient is receiving a breathing treatment at this time and oxygen saturation levels are slowly increasing. Keeping the RT in the loop allows them to be more prepared if they are needed. Typically, they will come and do their assessment on the patient and weigh their opinion in with the team on plan of care. Also give X-Ray a call and ask them to bring the portable x-ray for a one view chest x-ray.


Start fluids and give the steroid at this time. Confirm blood work has been drawn including blood cultures then administer IV antibiotics. In a perfect world the steroids would be given IV first, however, the IV needs to be established first and starting the breathing treatment is more important than waiting.


Throughout this process, the nurse needs to be constantly checking the patients’ oxygen saturation status. Make sure the patient is sitting up in the bed and not slouched over; make sure the pulse oximeter in placed correctly on the finger and is giving a good wave form before alerting anyone (e.g. physician or RT).


The plan of care at this point is waiting on blood and x-ray results as well as continuous pulse ox monitoring. During the waiting time for results, chart the assessment. This patient will likely be admitted for pneumonia and inability to keep oxygen levels up. Prepare the patient for admission (Updated vitals, all personal property is accounted for and with the patient, any abnormal results be addressed, family updated on plan of care, etc.).


Report to the floor will need to be called and the plan of care needs to be conveyed. For example:

This is a 54-year-old male who was complaining of shortness of breath upon exertion and cough. His chest x-ray showed pneumonia bilaterally in the lower lobes, and his blood work showed a WBC of 15,000. He has received a breathing treatment, steroids and fluids with little improvement in oxygen saturation. He hoovers in the high 80’s on RA and low 90’s with 2L nasal cannula. He is alert and oriented times four, ambulatory with oxygen or his saturation falls to low 80’s. He has received his first dose of antibiotics. The plan is to monitor his oxygen levels and administer IV antibiotics. He also has a consult to pulmonary medicine.


Nursing Care Plan and Clinical Judgement Example 3: Post-op Femur Break

clinical reasoning case study


An 18-year-old male who was hunting in a tree stand, fell about 20 feet landing on his right leg resulting in a right proximal femur comminuted fracture. He went into surgery to get his bone reduced and pins placed to keep his femur inline. The pedal pulses and post-tibial pulses are intact +2 bilaterally. His anesthesia has now worn off and he is on a morphine PCA pump that is scheduled for 1-3mg of morphine every 8-10 minutes with a limit of 70 mg in 4 hours. The surgery went as planned and without incident. Pins are in place and bleeding is controlled.


Head-to-toe assessment:

The patient is alert and oriented to person, place, time and situation. Pupils are equal, round, reactive to light, and accommodation. The patient is tired but eyes open spontaneously to voice.


Breath sounds are clear, breathing is even and non-labored, chest expansion is symmetrical. Oxygen saturation is 100% on room air.


Cardiac rate and rhythm is normal with 68 beats per minute, S1 and S2 auscultated, bilateral radial pulses +3, capillary refill is less than 3 seconds on both upper and lower extremities. All phalanges are able to move and wiggle. No swelling or edema noted at this time.


Skin is pink, warm, dry, and mucous membranes are moist and intact. The doctor will change the first dressing and it is not to be removed or changed before then, dressing intact, no leakage of blood or puss noted at this time.


Patient reports he had a bowel movement before surgery today (about 12 hours ago) and hasn’t had anything to eat or drink in 18 hours and he is super thirsty. Bowel sounds are active and abdomen is soft and non-tender in all four quadrants. Patient has a Foley intact with about 400 mLs of urine in the chamber. Patient states, “I will do whatever it takes to get better.”



NANDA-I nursing diagnosis:

Risk for constipation related to opioid pain pump secondary to postoperative pain as evidenced by decrease ability to move, constant opioid pain management, and interrupted nutrition.


Impaired physical mobility and walking related pain in right leg secondary to comminuted femur fracture as evidenced by surgical pins placed to keep femur in proper position.


Risk for infection related to surgical procedure secondary to femur fracture as evidenced by open wounds on skin.


Risk for impaired tissue integrity related to break in skin integrity as evidenced by surgical wound.


Readiness for enhanced urinary elimination related to Foley secondary to femur break as evidenced by patients’ current orientation and cooperation as well as motivation to get well.


Plan of care:

Monitor vital signs

Promote movement as early as possible

Discontinue Foley at appropriate time

Wound care

DVT prophylaxis and pain control (listen to this podcast on antithrobolytic therapy)


Implementing plan of care:

  1. Vital signs at least every 2 hours while patient is on PCA pump, can place patient on a monitor. (PCA policies will vary based on facility . . . ALWAYS refer to facility protocol)
  2. Ambulation, D/C Foley, wound care will all depend on the orders from the physician but working closely with the physical trainer and physician to make sure ambulation occurs as soon as possible. Provide wound care as ordered but only after the physician has changed the first dressing.
  3. Anti-thrombolytic, pain management and all other medications to be administered at the times they are ordered if indicated, remember you want to move the patient off of a PCA pump as soon as possible.



Nurses to-do list:

  • Initial assessment and pain control
  • Strict intake and output monitoring
  • Discontinue the foley per order.  If an order is not in place and it is clinically appropriate, discuss discontinuing foley with MD.  This is usually done when patient is mobile.
  • Bring wound supplies to bedside for the doctor to use for first change of wound care
  • Monitor and dress wounds as ordered
  • Start DVT prophylaxis (HEPARIN LOVENOX – MECHANICAL)
  • Communicate with PT and physician on when to start ambulating patient
  • Create a plan to move from PCA to PRN morphine and eventually oral pain medication
  • Continuous vital sign monitoring while on PCA pump. (refer to facility protocols)


What to do first:

Complete your initial assessment and administer any meds that are ordered at this time. Ensure pain is controlled.  If PCA has not been initiated, set it up and educate patient on not only how the PCA works, but also the plan to eventually transition to oral pain medications.  


The next task that should be completed is getting the supplies for wound care to the bedside just in case the physician shows up, you can be ready. This is the time you will want to do your own personal head to toe assessment and chart it.


Education on how a PCA pump works will help to progress the patient to PRN pain medications to oral pain medications. Then at the first scheduled heparin dose, make sure to be on time and continue to schedule.


Review activity order, clarify with MD if needed and collaborate with PT about how patient will safely ambulate (and if they need pain medication first).  Make sure the orders for a diet are in and that the patient understands why they have to eat slowly as well as progress slowly.


By the end of the shift, you need to re-assess the goals and communicate progression to the next shift nurse. For example:

Mr. Parker is 18-years-old and he fell from a tree while hunting in a tree stand, landing on his right leg and having a proximal comminuted femur fracture. He is now 12 hours post-op where they placed 4 pins in his leg. The doctor has been by to change the dressing and the wound is not draining or bleeding. Wound care instructions are to change the dressing every 12 hours and re-apply a nonstick dressing with bacitracin and wrap it with gauze. The patient will be seen by PT at 10am today and they will determine how much activity should be done today. He has been on bed rest all tonight. His PCA pump is of morphine 1-3mg every 8-10 minutes, he has only used it twice so when the doctors round perhaps we could look into getting the order changed to a PRN medication instead of a PCA pump. Once he is able to ambulate, We also need to ask about discontinuing his foley catheter.. He is on a liquid diet and he had some broth for dinner. He has not ordered breakfast yet but watch for progression to thickened liquids. He is alert and orientedx4, breathing is even and non-labored, and his cardiac rhythm is normal sinus rhythm.



Nursing Care Plan and Clinical Judgement Example 4: DKA


A 25-year-old female is brought into the emergency room via EMS for altered mental status and hyperglycemia. Per EMS, the patient was found wandering around the middle of the road and a neighbor called the police. EMS reports that upon arrival the client was hypotensive and had a blood sugar greater than 500. One 22-gauge IV is patent in the left antecubital and has a 500 mL bolus infusing. No family is present, the patient doesn’t know her name and her breath is fruity. A glucose re-check upon arrival the emergency room is >500.


Head-to-toe Assessment:

The patient is alert but not oriented, pupils are +3 bilaterally, equal, round and reactive to light, accommodation unable to be assessed at this time as patient doesn’t follow commands. Patient facial expressions are symmetrical.


Lung sounds are clear bilaterally, chest expansion is even and breathing is non-labored. Pulse oximeter reading is 100% and respirations are 24.


Cardiac rhythm at rate are normal sinus, heart sounds S1 and S2 are auscultated, capillary refill is less than 3 seconds, and radial pulses are +3 bilaterally.


Bowel sounds are active and abdomen is soft, no discomforted noted upon palpation of the abdominal quadrants.


All extremities are AROM, skin is pink, warm and dry. Patient continuously stating, “water.”


NANDA-I nursing diagnosis:

Adult failure to thrive related to poor glucose control as evidenced by hyperglycemia, altered mental status, and fruity breath.


Acute confusion related to hyperglycemia secondary to diabetes as evidenced by orientation status and inability to cooperate.


Self-neglect related to poor glucose control secondary to diabetes as evidenced by hyperglycemia and altered mental status.


Risk for unstable blood glucose level related to diabetes as evidenced by hyperglycemia, fruity breath and altered mental status.


Plan of care:

Fluids!!!! (download this cheatsheet on fluid therapy)

Insulin drip (learn about insulin here)

Monitor electrolytes (Anion gap) (learn about electrolytes here)

Glucose monitoring


Implementing plan of care:

  1. Fluids and an insulin drip through the IV with constant cardiac monitoring.
  2. Glucose monitoring is key to this entire problem. The patient will need to have hourly point of care glucose checks with the goal of transitioning to subcutaneous insulin administration.
  3. (Please note, many facilities have DKA protocols in place for appropriate IV insulin administration and subsequent transition to subcutaneous insulin).
  4. Monitor electrolytes every 6 hours and administer potassium as needed (Per protocol) with the goal of closing the anion gap.


Nurses to-do list:

  • Start a second IV-get blood work-note time.
  • Start insulin.
  • Vital signs/continuous cardiac monitoring.
  • Insert Foley.
  • Pull up diabetic ketoacidosis (DKA) protocol.



What to do first:

Your patients’ ABC’s are stable as well as vital signs. Thus, the very first thing that needs to happen is getting a set vital signs and hooking the patient up to the cardiac monitor. Delegate getting a second IV and blood work. NOTE the time that the blood work was drawn because in 6 hours another basic metabolic panel will need to be drawn to check electrolytes and check for closing of the anion gap. After getting blood and a second IV line it is vital to hang fluids.


Timing is crucial.


Next gather pump tubing and a pump for the insulin as soon as pharmacy prepares the bag for infusion.


The next thing to do would be to start a Foley because one mechanism of bringing the glucose down is loading the patient with fluids which is going to cause frequent urination and not having the patient be oriented or following commands, it is important to protect their skin from constant urination.


Additionally, it will be very important to monitor intake and output strictly. However, inserting a foley is not always part of this order set and depending on the physician, it may not be ordered.  Use your clinical judgement and critical thinking to determine if you should communicate with the provider regarding foley necessity. 


At this point it’s a manic waiting game of tweaks. Chart your assessment in between glucose checks and insulin adjustments as well as updating vitals. You will want to be checking this patients’ orientation status every time you do something. As the anion gap closes the patient will become more oriented, get the information you were unable to obtain when they were completely altered. Make sure to be watching for the blood work results and treating any metabolic acidosis as appropriate as well as adjusting the potassium per protocol. The last step here would be getting this patient to a possible ICU or step-down ICU room. Report to the floor would look something like this:

This is a 25-year-old female in diabetic ketoacidosis. She was brought in via EMS for wandering around the middle of the road. Upon arrival she was alert and oriented to nothing, she did not have any ID or cell phone on her. She is currently alert and oriented times four and reports her name is Alicia. We got ahold of her family and they are on their way. She has 2 IV’s, one in each AC and has received 3,500 mL of normal saline. Her initial glucose from lab was 895. We started her insulin drip at 13:50 and her re-draw is due at 19:50. The insulin is running at 15 units and hour and the last glucose check at 17:00 was 489. Next glucose check is due at 18:00. She has a Foley intact that has drained 2,000 mL of urine. She has 1 bag of normal saline hanging and it is running at 125 mL per hour. All vital signs are within normal limits.





One of the most frustrating thing to me when I was in nursing school was that the answer to a question seemed to depend on the person or instructor giving the answer. In other words, it was JUST an opinion. WHY am I being tested on someone else’s opinion? I honestly can’t answer that.


Take note that the NCLEX and nursing practice ALWAYS follows the ABC’s. After the ABC’s it can be a little bit of a guessing game with some great reasons for all answers.  This is when using your nursing clinical judgement is so essential in developing and implementing nursing care plans. I tend to lean towards getting a set of vital signs if the patients’ ABC’s are stable. It can also depend on the grove you get into when you start to see your patients.


These are just my thoughts on the process with my reasons for why I do what I do. With the exception of some things requiring a specific order of operations (Blood cultures before antibiotics) it really is about how to be as safe as possible so keep that idea floating about in your head when you act on what to do first (or answer an NCLEX question).


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Please keep in mind that we discuss general plans of care for various disease processes and typical orders associated with diseases processes.  Nurses should never implement anything without the appropriate order or a protocol/procedure in place.  Full disclaimer in footer.

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