Student Name: Grace Kim

Date: 11/7/14
N360 Weekly Self Evaluation

1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
Potential Complications
Dehydration

Electrolyte imbalance

Glucose abnormality

Wound dehiscence

Infection

Sepsis

Septic shock

Tissue death

Reoccurance (of SBO)

Early Recognition
Dry mouth and skin, dizziness,
increased
thirst,
headache,
tired/sleepy,
decreased
UOP,
concentrated urine
Muscle
spasm,
weakness,
irregular heartbeat, confusion, BP
changes, fatigue
Hypoglycemia: sweating, pallor,
confusion, lethargy, coma
Hyperglycemia: increased thirst,
headache, blurred vision, frequent
urination, tingly sensation in
mouth, fruity smelling breath
Bleeding,
pain,
inflammation,
fever, redness, wound opening
spontaneously,
pus/drainage,
broken sutures
Purulent
discharge,
redness,
tenderness, fever, pain, swelling,
warm to touch, increased WBC
Chills, body aches, N/V, vertigo,
confusion, lethargy, fatigue, lowgrade fever
Patches
of
discolored
skin,
reduced
UOP,
confusion,
palpitations, tachycardia, chills,
extreme
weakness,
lightheadedness
Severe pain, warm/red/purple skin
with swelling, ulcers/blisters/black
spots on skin
Abdominal pain, N/V, bloating,
frequent loose stools and flatus,
hyperactive bowel sounds

Air embolism

Difficulty breathing, respiratory

failure, stroke, chest pain, heart
failure, change in LOC, low BP,
blue skin hue

Catheter occlusion

Sluggish catheter, appearance of

clots on exterior of catheter,

Prevention
Drink lots of fluids, if NPO then IV
fluid replacement

Diet changes, IV fluids, electrolyte

replacement,
treat
underlying
cause
Monitor glucose often, administer
subcu insulin as needed, adjust
insulin dose in TPN, taper
concentrated dextrose infusions

Reduce stress on wound edges,

avoid
heavy
lifting,
avoid
hematomas, proper wound care,
maintain hydration
aseptic technique, cleaning the
wound, antibiotics
Prevention of infection

Prevention of sepsis

Prevention of infection, leading to

sepsis
Manage underlying conditions;
otherwise no current guidelines of
prevention. Eat smaller meals
more frequently throughout the
day,
keep
hydrated,
avoid
fatty/greasy foods, avoid lactose
and gas-forming foods (broccoli,
beans, gum)
Ensure
all
lumens
are
capped/clamped,
fully
prime
tubing, expel air from syringes prior
to injections, prevent tubing
misconnections, inspect insertion
site regularly, ensure integrity of
PICC dressing, use caution when
repositioning patients
Flush catheter with NS before and
after med administration, ensure

unable to draw back syringe

Thrombosis

Catheter malposition

Catheter rupture

Phlebitis

Swelling near point of occlusion,

venous
distention,
pain,
tenderness, edema, warm to touch
Changes in catheter patency, loss
of blood return, discomfort in upper
arm, shoulder, chest during
infusion, external catheter length
difference from time of insertion
Resistance when flushing catheter

Erythema, edema, pain, swelling,

tenderness,

catheter is not clamped or kinked,

reposition
client,
prophylactic
anticoagulants, positive pressure
flushing
Same as above

Proper catheter securement, use

of securement devices as opposed
to sutures, avoid taping over body
of catheter
Avoid applying luer-locks too
tightly, avoid tangling catheter in
linens/pt clothing/equipment, avoid
using syringes smaller than 10cc
Proper hand hygiene, disinfection
of hub before catheter access,
assess insertion site

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 think I am better at using the nursing process to plan my care. I feel that my assessments are
thorough, but I need to work on the diagnosis and planning. For example, sometimes my expected
care plan differs from what I found after the clinical day. However, I implement care according to the
care plan and document everything. At the end of the clinical day, I am able to evaluate the
effectiveness of my care. See NCP.
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 patients. For example, both of my
patients this week were GI patients (ileostomy, crohns disease), so my focused assessment was
abdominal. My primary nursing diagnoses were risk for infection, acute pain r/t surgery, and impaired
bowel function. An additional concern for me regarding my second patient was risk for DVT, because
he refused to use the sequential compression device. However, he did walk for me once during my
shift.
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 developing well. I am being pretty thorough with focused
assessments, and since Ive had a lot of GI patients, I was able to practice focused GI assessments
several times. Also, this week I discovered a stage 2 pressure ulcer on one of my patients while doing
a bed bath. One thing that is still difficult for me is percussing. I am trying to improve by watching
youtube videos and practicing on family.
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 implement 2 new skills this week: IVPB and IV push. I completely did horrible. I could
have done better if I was more prepared with my second patient and studying how to administer an IV
push medication. It was embarrassing and frustrating and should never happen. I did ask for help
when I needed it.
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?
I think I could still work on my time management. This week I had 2 patients, and I was so busy I
didnt have time for a lunch break. One area of difficulty I found was being assertive with the nurse

aides who try to delegate their bed baths and linen changes to the students. I need to work on being
more assertive and firm, and telling people no. Otherwise, I will not get anything done. I try to
monitor my time management by sticking to my daily plan of care.
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 letting the primary RN know about my patients pressure ulcer situation. She was not
aware of it prior to me telling her, so together we went to the patient and took a look at it. We agreed
that although it was a small ulcer (0.5cm), it was stage 2 because the skin was broken. Also, there
was redness 1cm in diameter around the ulcer.
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. Assess surgical site for S&S of infection. This was my priority because the patient was postop
day 2. The surgical site was well approximated with staples, with no redness, swelling, or
drainage.
2. Perform focused abdominal assessment. This was my second priority because my patient
had an ileostomy reversal. His GI function had not yet returned. He had hypoactive bowel
sounds and a distended abdomen, but it was round and soft. He was also still NPO.
3. Assess catheter insertion site. This was my third priority because I wanted to ensure that
there were no S&S of infiltration/phlebitis/infection.
4. Assess pain (location, characteristics, intensity). This was my fourth priority because my
patient was a recent postop and could not clearly describe his pain. However, he did state
that his pain level was 3/10 and that he did not want any medication for it.
5. Administer IV fluids as ordered. This was also a priority because my patient was at risk for
dehydration d/t NPO status.
6. Assist patient with ROM and ambulation. This was another priority because my patient was at
risk for DVT, and ambulation helps to promote GI function as well. My patient ambulated for
me 3x throughout my shift.
7. Assess patients ability to perform ADLs effectively and safely. This was important because
my patient had limited abdominal strength.
8. Perform a bed bath. This was on my intervention list because my patient told me that he had
not received a bed bath the day before, and he was not happy about it.
Patient 2:
1. Perform focused abdominal assessment. This was my priority because my patient was
admitted for possible SBO.
2. Monitor tolerance to advancing diet. This was my second priority because the patient was just
placed on a clear liquid diet after having been NPO. The morning of clinical was the first day
that he finally passed flatus.
3. Assess catheter insertion site. This was my third priority because I wanted to ensure that
there were no S&S of infiltration/phlebitis/infection, especially on a PICC.
4. Monitor for S&S of TPN complications. This was another priority because there are several
complications that could arise from TPN use, such as hyperglycemia.
5. Assist patient with ROM and ambulation. This was also a priority because my patient refused
to use the sequential compression device, and he only ambulated once in the hallway.
6. Assess pain (location, characteristics, intensity). This was not a high priority because this
patient did not have complaints of pain.
7. Assess patients ability to perform ADLs effectively and safely. It is always important to
gauge your patients limitations. My patient could perform ADLs on his own, but needed
some assistance with the bed bath.