Integrating Clinical Reasoning with Evidence-Based Patient Care

Course Resources

• Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International. https://doi.org/10.1891/9780826195517
• Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification 2024-2026 (13th ed.). Thieme Medical Publishers.
• Melnyk, B. M., Fineout-Overholt, E., & Giggleman, M. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.
• Warren, J. I., McLaughlin, M., Bardsley, J., Eich, J., Esche, C. A., Kropkowski, L., & Risch, S. (2019). The strengths and challenges of implementing EBP in healthcare systems. Worldviews on Evidence-Based Nursing, 16(3), 166-175. https://doi.org/10.1111/wvn.12369
• Yoo, J. Y., Kim, J. H., Kim, J. S., Kim, H. L., & Ki, J. S. (2019). Clinical nurses’ beliefs, knowledge, organizational readiness and level of implementation of evidence-based practice: The first step to creating an evidence-based practice culture. PLOS ONE, 14(12), e0226742. https://doi.org/10.1371/journal.pone.0226742

Course: NUR 3165 – Advanced Health Assessment and Clinical Reasoning

Assessment Title: Comprehensive Evidence-Based Nursing Care Plan with Clinical Application

Academic Year: 2025

Semester: Fall 2025

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ASSESSMENT OVERVIEW

Purpose

This assessment evaluates your ability to integrate theoretical knowledge with clinical practice by developing a comprehensive, evidence-based nursing care plan for a patient with complex health needs. You will demonstrate competency in utilizing the nursing process (assessment, diagnosis, planning, implementation, and evaluation) while incorporating current research evidence and best practices in patient-centered care.

Learning Outcomes

Upon successful completion of this assessment, students will be able to:

1. Conduct a holistic patient assessment incorporating physiological, psychological, sociocultural, and spiritual dimensions
2. Formulate accurate NANDA-I approved nursing diagnoses based on comprehensive assessment data
3. Develop measurable, patient-centered goals and outcomes using SMART criteria (Specific, Measurable, Achievable, Relevant, Time-bound)
4. Design evidence-based nursing interventions supported by current scholarly literature (2019-2025)
5. Demonstrate critical thinking and clinical reasoning in prioritizing patient care needs
6. Evaluate patient outcomes and modify care plans based on patient response
7. Apply professional standards and ethical principles in nursing practice

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ASSESSMENT TASK DESCRIPTION

Part A: Patient Case Selection and Comprehensive Assessment (30%)

Select ONE patient from your clinical placement who presents with at least two concurrent health conditions or complex health needs. Obtain appropriate consent and maintain confidentiality by using pseudonyms throughout your assignment.

Complete the following:

1. Patient Profile (300-400 words)
   • Demographic information (age, gender, cultural background)
   • Medical history and current diagnoses
   • Current medications and treatments
   • Relevant psychosocial factors (living situation, support systems, employment)
   • Cultural, spiritual, or religious considerations affecting care
2. Comprehensive Health Assessment (800-1000 words)
   • Systematic physical assessment findings organized by body systems
   • Mental health and cognitive status assessment
   • Pain assessment (if applicable)
   • Nutritional assessment
   • Functional ability and activities of daily living (ADLs)
   • Risk assessments (falls, pressure injuries, infection, etc.)
   • Laboratory and diagnostic test results with interpretation
   • Current symptoms and patient’s subjective experience

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Part B: Nursing Diagnoses and Prioritization (20%)

Identify and prioritize THREE nursing diagnoses using NANDA-I taxonomy (400-500 words):

1. State each nursing diagnosis in the PES format:
   • Problem: NANDA-I diagnosis label
   • Etiology: Related to (contributing factors)
   • Signs/Symptoms: As evidenced by (defining characteristics)
2. Provide a clear rationale for each diagnosis with supporting assessment data
3. Prioritize the three diagnoses using Maslow’s Hierarchy of Needs or another appropriate prioritization framework, with justification for your ranking

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Part C: Evidence-Based Care Planning (40%)

For each of the three prioritized nursing diagnoses, develop a comprehensive care plan (approximately 600-800 words per diagnosis):

1. Patient-Centered Goals and Expected Outcomes

• Write at least two SMART goals for each diagnosis
• Include short-term (within 7 days) and long-term (discharge/ongoing) outcomes
• Ensure goals are measurable and realistic for the patient’s condition

2. Evidence-Based Nursing Interventions

• Identify 4-6 nursing interventions for each diagnosis
• Classify interventions using the Nursing Interventions Classification (NIC) when applicable
• Provide strong rationales for each intervention, citing current evidence-based literature (minimum of 3 peer-reviewed sources published 2019-2025)
• Include both independent nursing actions and collaborative interventions
• Consider pharmacological and non-pharmacological approaches
• Incorporate patient education and health promotion strategies
• Address cultural competence and patient preferences

3. Evaluation Criteria

• Describe specific criteria and methods for evaluating goal achievement
• Identify relevant clinical indicators and patient responses to assess
• Explain how you would modify the care plan if outcomes are not met

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Part D: Clinical Reasoning and Reflection (10%)

Write a reflective analysis (500-600 words) addressing:

1. Clinical Reasoning Process
   • Describe your decision-making process in developing this care plan
   • Discuss any challenges encountered in applying theoretical knowledge to clinical practice
   • Explain how you resolved conflicting priorities or complex clinical situations
2. Professional Development
   • Reflect on what you learned through this assessment
   • Identify areas for continued learning and professional growth
   • Discuss how this experience will inform your future nursing practice
3. Ethical and Legal Considerations
   • Address any ethical dilemmas or considerations in this patient’s care
   • Discuss how you maintained patient confidentiality and dignity
   • Explain how professional standards guided your practice

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FORMATTING AND PRESENTATION REQUIREMENTS

General Requirements

• Word Count: 3,500-4,500 words (excluding references and appendices)
• Format: Microsoft Word document (.docx) or PDF
• Font: Times New Roman or Arial, 12-point
• Spacing: Double-spaced
• Margins: 1 inch (2.54 cm) on all sides
• Page Numbers: Bottom center of each page
• Headings: Use APA Level 1, 2, and 3 headings to organize content

Structure

Your paper should include:

1. Title Page (student name, student ID, course code, assessment title, date)
2. Table of Contents
3. Introduction (150-200 words)
4. Main Body (Parts A, B, C, D as outlined above)
5. Conclusion (150-200 words)
6. Reference List (minimum 10 peer-reviewed sources, 2019-2025)
7. Appendices (if applicable: blank care plan template, assessment tools used)

Citation Style

• Use APA 7th Edition formatting throughout
• Include in-text citations for all evidence-based claims
• Reference list must contain at least 10 credible, peer-reviewed sources
• At least 6 sources must be from nursing or healthcare journals published between 2019-2025
• Acceptable sources include: peer-reviewed journal articles, clinical practice guidelines, government health publications, and authoritative textbooks

Academic Integrity

• This is an individual assessment
• All work must be original and properly referenced
• Similarity index must not exceed 20% (excluding reference list)
• Plagiarism, collusion, or contract cheating will result in academic penalties
• Patient confidentiality must be maintained at all times (use pseudonyms)

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SUBMISSION REQUIREMENTS

Due Date

Friday, November 21, 2025, by 11:59 PM (EST)

Submission Method

Submit your completed assessment via the Moodle assignment portal:

• Upload a single document file (Word or PDF)
• File naming convention: LastName_FirstName_NUR3165_CarePlan.docx
• Ensure the file is not corrupted before submission
• Late submissions will incur a 5% penalty per day unless prior extension approval is granted

Extensions

Extensions may be granted only under exceptional circumstances (serious illness, family emergency, or significant hardship) with appropriate documentation. Requests must be submitted at least 48 hours before the due date via the MRU Student Services portal.

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ASSESSMENT RUBRIC

Criteria	Excellent (A)	Proficient (B)	Satisfactory (C)	Needs Improvement (D/F)	Weight
Patient Assessment & Data Collection	Comprehensive, systematic, holistic assessment with rich detail and clinical insight	Thorough assessment covering all required elements with good detail	Basic assessment covering most elements with adequate detail	Incomplete or superficial assessment missing key components	30%
Nursing Diagnoses & Prioritization	Three accurate NANDA-I diagnoses with clear PES format; excellent prioritization with strong rationale	Three appropriate diagnoses with correct format; good prioritization with adequate rationale	Diagnoses mostly appropriate with minor format issues; basic prioritization	Inaccurate diagnoses or incorrect format; poor or missing prioritization	20%
Evidence-Based Care Planning	Highly relevant, evidence-based interventions with strong scholarly support; SMART goals clearly stated; excellent integration of theory and practice	Appropriate interventions with good evidence support; clear goals; good theory-practice integration	Basic interventions with some evidence support; goals stated but may lack specificity; adequate theory-practice connection	Limited or inappropriate interventions; weak or no evidence support; vague goals; poor theory-practice integration	40%
Clinical Reasoning & Reflection	Demonstrates exceptional critical thinking, insight, and self-awareness; sophisticated analysis of clinical decision-making	Shows good critical thinking and reflection; clear analysis of decision-making process	Basic reflection with some critical thinking; simple analysis of decisions	Superficial reflection; limited critical thinking or analysis	10%
Academic Writing & Presentation	Excellent academic writing; flawless APA formatting; well-organized with clear structure; no errors	Good academic writing; minor APA errors; well-organized; few grammatical errors	Adequate writing; several APA errors; organization could be improved; some grammatical errors	Poor writing quality; numerous APA errors; poorly organized; many grammatical errors	Pass/Fail

Grading Scale:

• A: 90-100% (Excellent)
• B: 80-89% (Proficient)
• C: 70-79% (Satisfactory)
• D: 60-69% (Needs Improvement)
• F: Below 60% (Fail)

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RESOURCES AND SUPPORT

Recommended Resources

• NANDA International: NANDA-I Nursing Diagnoses: Definitions and Classification 2024-2026
• Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC)
• MRU Library databases: CINAHL, PubMed, Cochrane Library, ProQuest Nursing & Allied Health
• Clinical practice guidelines from professional organizations (ANA, CDC, NIH)

Academic Support Services

• Writing Center: Available for assistance with academic writing, APA formatting, and structure
• Library Services: Research librarians available for database searching and reference management
• Clinical Faculty: Office hours available for consultation on care plan development
• Peer Tutoring: BSN peer tutors available for review and feedback

Contact Information

Course Coordinator: Dr. Maria Rodriguez, DNP, RN Email: [email protected] Office: Nursing Building, Room 305 Office Hours: Tuesdays and Thursdays, 2:00-4:00 PM, or by appointment

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IMPORTANT NOTES

1. Clinical Placement Requirement: This assessment requires you to have completed at least 40 hours of clinical placement to ensure adequate patient exposure and assessment opportunities.
2. Patient Consent: Verbal consent must be obtained from the patient (or legal guardian if applicable) before including them in your case study. Document consent in your clinical log.
3. Confidentiality: Under HIPAA and institutional policies, all patient information must be de-identified. Use pseudonyms for patients and avoid including any information that could identify the individual or healthcare facility.
4. Professional Conduct: This assessment reflects your professional nursing practice. Demonstrate respect, empathy, and ethical behavior in all patient interactions and documentation.
5. Feedback: Marked assessments with feedback will be returned within three weeks of submission via Moodle. Students are encouraged to review feedback to support ongoing learning.

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Good luck with your assessment! This is an opportunity to demonstrate your growth as a nursing professional and your commitment to evidence-based, patient-centered care.