Student Name: Grace Kim

Date: 12/1/14
N360 Weekly Self Evaluation

1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
Potential Complications
Falls
Hypoxemia/Hypoxia

Recurrent infection

Sepsis

Tissue death

Catheter occlusion

Thrombosis

DVT

Pulmonary embolism

Stroke

MI

Heart failure

Bile peritonitis

Early Recognition
Unsteady
gait,
orthostatic
hypotension,
dizziness,
lightheadedness
SOB,
wheezing,
sweating,
tachypnea, skin color changes
(blue to cherry red), cough
Purulent
discharge,
redness,
tenderness, fever, pain, swelling,
warm to touch, increased WBC
Chills, body aches, N/V, vertigo,
confusion, lethargy, fatigue, lowgrade fever
Severe pain, warm/red/purple skin
with swelling, ulcers/blisters/black
spots on skin
Sluggish catheter, appearance of
clots on exterior of catheter,
unable to draw back syringe

Swelling near point of occlusion,

venous
distention,
pain,
tenderness, edema, warm to touch
Leg fatigue, pain or swelling in
legs, visible veins

Sudden onset SOB, syncope,

chest pain/discomfort, dizziness,
coughing which may bring up
blood, rapid breathing
Sudden numbness or weakness of
face/arm/leg, sudden confusion,
sudden trouble speaking, sudden
blurred vision, sudden loss of
balance, severe headache
SOB, chest discomfort or pain,
upper body pain, sweating,
anxiety, lightheadedness, N/V
SOB, fatigue, weakness, edema,
arrhythmias,
cough,
ascites,
weight gain, high BP, chest pain
Poor
appetite,
nausea,
dull
abdominal pain increasing to
persistent/severe pain, abdominal
tenderness, distention

Prevention
Check BP when laying down,
sitting, and standing up. Provide a
walker. Assist with ambulation.
Keep HOB elevated, positioning,
pursed lip breathing, diaphragmatic
breathing, stop strenuous activity,
monitor O2 and breathing
Aseptic technique, cleaning the
wound, antibiotics
Prevention of infection

Prevention of infection, leading to

sepsis
Flush catheter with NS before and
after med administration, ensure
catheter is not clamped or kinked,
reposition
client,
prophylactic
anticoagulants, positive pressure
flushing
Same as above

Assess CMS, ambulation/ROM,

use of sequential compression
device while in bed, reposition
Q2H, anticoagulants
Prevention of DVT.

Control high BP, control diabetes,

maintain healthy weight, exercise,
anticoagulants, anti-platelet drugs

Quit smoking, control high BP, stay

active, eat healthy, reduce/manage
stress
Same as above

Prevention of bile leak

Diabetes

Kidney failure

Malnutrition

Frequent
urination,
excessive
thirst, increased hunger, weight
loss, fatigue, blurred vision, tingling
sensation in hands or feet, lack of
interest
and
concentration,
frequent infections, slow healing
wounds
Decreased UOP, fluid retention,
edema, drowsiness, SOB, fatigue,
confusion,
nausea,
seizures,
coma, chest pain
Lack of energy, fatigue, delayed
wound healing, irritability, poor
concentration, inability to keep
warm,
persistent
diarrhea,
depression, 5-10% unplanned
weight loss over 3-6mo.

Exercise regularly, watch weight,

diet, increase intake of fiber and
whole grains

Manage diabetes and/or high BP,

diet modification, exercise, regular
tests (urine test, FBG test,
creatinine),
maintain
healthy
weight, quit drinking/smoking
Eat a balanced diet

2. Am I getting more comfortable with the use of the nursing process to plan and evaluate nursing care?
(Give examples of how it is better now or problems that still bother you).
I am much more comfortable with the use of the nursing process to plan and evaluate nursing care.
For example, this week I had 2 patients. What I expected to find before the start of the first clinical
day was exactly what I found. Although we did not have to fill out a mini NCP this week, there were
no surprises for me, except for the discovery of a new diagnosis for my first patient (kidney failure).
3. Were my nursing diagnosis and plan of care individualized for my patients? (Give examples of how
you did this.) Do I have difficulty in this area? (Explain).
My nursing diagnoses and plan of care were individualized for my patient. For example, my first
patient this week was admitted for cholecystitis, but was retained due to a bile leak after the
cholecystectomy. My primary focus for her was abdominal because she was not tolerating PO intake.
I also monitored the JP drain to make sure there were no blood clots or blood being drained. It was
also discovered that she had kidney failure. My second patient was admitted for necrotizing fasciitis.
My primary focus for him was his right arm. I assessed for S&S of infection, CMS, and pain. I also
monitored his respiratory status because of his history of SOB.
4. How are my assessment skills developing? Am I being as thorough as I need to be? What areas are
still difficult for me and what am I doing to improve? (Be specific).
I feel that my assessment skills are well developed at this point. I am being very thorough and have
noticed several abnormalities. For example, when I was assessing my patients, I found that my first
patient had both numbness and tingling to her lower extremities, and my second patient still had
numbness to his right arm. However, no one knew about it until I reported it to the nurses. Also, I
thought I discovered an abnormal heart rhythm on my first patient, but later I learned that there was
an EKG strip in her hard chart. It was just not diagnosed.
5. What new skills did I implement this week? How did I do? What could have helped me to improve?
Did I ask for help when I needed it?
I was able to work with a JP drain for the first time this week, and do a dressing change as well. I did
okay considering that it is pretty simple. I also assisted the wound nurse again, and she gave me
some helpful tips about the nursing career. I also gave a few more subcu shots. I dont think I needed
any help so I didnt ask for any.
6. How is my time management progressing? What areas of difficulty have I found and what can I do to
improve? How do I monitor my time management while in the clinical area?
My time management must be progressing well because I am finding myself with more and more
downtime. Even with 2 patients this week, I found myself sometimes with nothing to do. I even took a

leisurely lunch. I was with the wound nurse for a long time and was stuck having to take vitals on my
second patient Q15min for an hour, but I still had time to ambulate 3x with my first patient and do
everything else I needed to do. I even got both of my DARs written in before 1200.
7. Was I involved in making referrals for my client in any way? How could the nursing role in this
process have been strengthened?
I was involved in making referrals for my first client. When I first conducted my head-to-toe
assessment, my patient told me that her legs were very cold. When I asked about any numbness and
tingling, she said that both of her legs had numbness and tingling present. I then asked if this was
normal for her and she said that its been that way for years and she that just cant get warm.
Throughout the day, I kept asking about her cold feet and numbness/tingling. She would always
refuse an extra blanket or extra socks, but I finally told her that its ok to ask for one and that I could
even get her a bear(?) blanket. She eventually agreed and told me she would like to try it.

8. List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.
Patient 1:
1. Perform focused abdominal assessment. This was my highest priority because my patient
was unable to go home due to inability to tolerate PO intake.
2. Monitor fluid & electrolyte balance. This was my second priority because my patient has been
NPO for quite some time.
3. Assess CMS. This was my third highest priority because my patient had numbness and
tingling to both lower extremities from the knee down. It could have been a sign of DVT,
however her cap refill was <3seconds and she ambulated very well.
4. Monitor heart status. This was my fourth priority because my patient had an abnormal heart
rhythm. She also had hypertension, but my patient stated that she usually has good BP and
that her high BP only began after being hospitalized.
5. Assess pain (location, characteristics, intensity). This was another priority because my patient
was a postop patient, but she did not have any pain.
6. Assess catheter insertion site. This was my next priority because I wanted to ensure that
there were no S&S of infiltration/phlebitis/infection.
Patient 2:
1. Assess wound for S&S of recurrent/worsening infection. This was my first priority because my
patient was admitted for necrotizing fasciitis due to neglect of initial infection.
2. Perform focused lung and breathing assessment. This was my second priority because my
patient is a chronic smoker, his O2 was around 94-95, and his respirations were slightly high.
He also has a history of SOB (per pt, not diagnosed or noted in charts). According to ABC,
this should be a top priority.
3. Assess CMS. This was my third highest priority because my patient had edema +1, and he
reported some numbness to his right extremity. He also was high risk for DVT.
4. Assist patient with ROM. This was my fourth priority because my patient refused to use the
sequential compression device, and refused to ambulate. He was at a high risk for DVT.
5. Assess pain (location, characteristics, intensity). This was my fifth priority because my patient
hid his pain level very well and never complained. However, he was in a lot of pain when the
wound vac nurse was changing the wound vac dressing.
6. Assess catheter insertion site. This was my next priority because I wanted to ensure that
there were no S&S of infiltration/phlebitis/infection on my patients new PICC.
7. Assess patients ability to perform ADLs effectively and safely. It is always important to
gauge your patients limitations. My patient could perform some ADLs on his own, but he
was sometimes incontinent. His gait was also very unsteady.