Care Plan Reflection – Description
Students need to identify a patient/client they cared for in the clinical. Complete the following
sections of the reflective journal on the selected patient/client and your particular clinical
experience.
Part 1: Care Plan Reflection
1. Write a brief description of the patient/client:
? Patient Demographics
? Patient History
? Pathophysiology of condition
2. Indicate how you conducted the following components of the patient/client’s care plan
during your interaction:
? Assessment
? Diagnosis (choose one priority diagnosis)
? Planning
? Implementation
? Evaluation
3. Describe how you applied the Clinical Judgment Model during interaction:
a) What did you do to identify the patient/client needs?
b) What forms of assessment and team collaboration did you utilize to formulate the
patient/client needs?
c) How did you decide on the priority need of you patient/client?
d) How did you identify which nursing interventions will address the patient/client
priority needs?
e) How did you implement the solutions identified? Enumerate some steps/actions.
f) Were the steps/actions effective on not? Explain.
Part 2: Self-reflection
4. Describe your physical and mental experience while caring for the patient/client. Include
self-perception, behavior, or habit that you observed about yourself.
5. Note any feelings you observed in yourself, the patient/client, and/or others around you
at that time.
6. Evaluate own processes of decision-making, planning, or evaluation of activities
undertaken during the conduct of care.
7. Evaluate your own pre-judgments of the clinical situation and whether that could have
influenced your practical actions.
8. Evaluate your own needs for improving nursing, communication, or other skills to become a
professional nurse.
9. Evaluate own rash judgment on people, i.e., making judgments without sufficient evidence/
limited information.
10. Describe what specific nursing routines/practices you followed during the care. Would you
change the perspective routine to serve the patient/client better? Explain your answer.
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