Student Name Jeff Fernandez

Date 11/21/16
N360 Weekly Self Evaluation

1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
Potential
Complications
Pt 1
Lumbar
spondylolisthesis/
stenosis
Laminectomy,
lumbar fusion
Risk for spinal
trauma

Risk for infection

(surgical site)

Risk for
compartment
syndrome

Early Recognition

Prevention

-back pain
-paresthesia
-paralysis
-loss of bowel and/or bladder
control

-demonstrate log rolling technique

-pt will utilized skills learned in PT and
OT to prevent spinal trauma
-have pts family assist with mobility
-teach pt to not turn, twist, or bend at
the waste.
-back precaution education
-utilize
aseptic
technique
when
handling surgical site (dressing
change, inspection)
-monitor CBC (elevation in WBC)
-assess VS
-assess surgical site (pain, swelling,
warmth, drainage, smell, etc)
-don
gloves
when
performing
interventions
-teach pt signs and symptoms of
infection
-tell pt to report when signs and
symptoms are present
-cold compress at surgical site
-elevation of limb
-assess site for swelling, redness and
bruising
-assess lower extremities for paralysis
and paresthesia
-utilization
of
venodynes
and
stockings
-ROM as tolerated
-assist with repositioning every 2
hours

-fever, chills
-redness,swelling, inflammation
-tenderness
-delayed heeling
-warmth
-increase WBC
-sweats
-stiff neck
-diarrhea
-altered mental status

At lower extremities
-pain
-absent pulses
-swelling
-redness/ discoloration
-coolness
-paralysis
-numbness
-tingling
-burning
-bruising
-cramping
-feelings of tightness or fullness
-difficulty moving

-remove any constrictions

-keep body part below level of heart
-o2 therapy
-IV fluids
-pain meds
-stretching, PT

Risk for DVT

Acute pain

Risk for bleeding

constipation

Risk for
atelectasis/
pneumonia
(prolonged bed
rest)

Risk for Falls

-pain, swelling, and tenderness in

leg
-warm, red, skin in area of clot
-cramping at affected leg

-facial grimacing
-increased heart rate
-moaning
-restlessness
-tachycardia
-increase BP
-increase RR
-pt reports pain

-utilization of venodynes
-assessment of lower extremities (6
Ps)
-ROM as tolerated
-assist with reposition every 2 hours
-anti-coagulation therapy
-encourage early ambulation
-utilize PCA morphine (post-op)
monitor respiratory system
-do not ambulate without proper
assistance
-obtaining optimal bed position
-demonstrate proper back precaution
movements (no twisting, no turning,
no bending, log-roll movement)

-drainage from surgical site

-low BP
-increased HR
-weakness
-SOB
-pallor
-clammy skin
-dizziness
-decrease H&H
-inability to move bowels
-having lumpy or hard stools
-straining
-feeling as if a blockage is
causing inability to move bowels
-feeling as if stool has not been
completely emptied
-difficulty breathing
-shallow breathing
-shortness of breath
-coughing
-fever
-chills
-tachycardia
-chest tightening/pain
-tachypnea
-dull percussion over affected
lobe
-diminished breath sounds from
affected lobe or crackles
-tracheal deviation
-decrease chest excursion
-decrease o2 saturation

-assess surgical site

-proper wound care
-therapeutic dose of anticoagulants
-assess
clotting
labs
before
administering anticoagulants
-assess CBC (H&H)

-pt has unsteady gait

-pt is generally weak
-hypotensive
-altered LOC
-noncompliant to calling
assistance with ambulation

-correct hypotension
-check BP before ambulating
-bed at lowest position
-side rails up
-bed alarm
-call light within reach
-remove clutter on floor

for

-administer Colace
-promote physical activity as tolerated
-increase fiber intake
-administer suppository
-monitor bowel movement if any. Note
amount, color, and form
-deep breathing
-change position every 2 hours
-coughing
-use of incentive spirometer 10 times
an hour
-encourage early ambulation as
tolerated
-maintain HOB to promote postural
drainage and ease of breathing
-prn suctioning
-antibiotic therapy
-o2 therapy
-CPAP
-chest tube
-chest xray

-slow postural changes

-ensure pt complies with calling for
assistance
Pt 2
Hematuria,
Anemia
Risk for
myocardial
infarction

-tight in chest
-pain at chest, back, jaw,
shoulder
-pain that radiates to shoulder
-SOB
-sweating
-chills
-nausea and vomiting
-pallor
-anxiety
-dizziness, lightheadedness
-tachycardia
-weakness/ fatigue
-altered LOC

-assess family history risk

-maintain healthy diet and exercise
-quit smoking
-maintain healthy BP
-maintain cholesterol levels
-manage stress

Urine retention

-inability to urinate
-urgent need to urinate
-pain in lower abdomen
-bladder distention
-difficulty completely voiding
urine
-inability to feel fullness of
bladder
-straining

-administered prostate medication

-avoid OTC cold and allergy meds
-bladder scan
-catheter
-urethral dilation
-bladder drainage
-maintain sterility during interventions
to prevent UTI

Risk for urinary

tract infection

-burning when urinating

-urinary frequency
-pain at lower abdomen
-cloudy,
dark,
bloody,
foul
smelling urine
-fever
-chills
-fatigue
-weakness
-apathy
-SOB
-headache
-confusion
-pale skin
-pica, upward curvature of nails
(if iron deficient)
-paresthesia,
numbness,
unstable gait, dementia (B12

-perform sterile catheter care

-empty foley per facility policy or prn
-maintain sterility at tip of drain
-note characteristics of urine
-monitor I&Os
-ensure foley bag is below bladder to
prevent backflow into bladder
-eat vitamin rich diet (iron, folate, B-12,
C)
-iron supplement
-increase iron intake (beef, pork, fish,
poultry, dried fruit)
-prevent blood loss
-correct blood loss condition
-blood transfusions
-o2 therapy

Anemia

-monitor troponin levels

-12-lead ekg monitoring
-administer nitroglycerin
-aspirin
-nitroglycerin
-morphine (decrease anxiety)
-o2 therapy
-meds (beta blockers, ace inhibitors,
statin, anticoagulants)
-dilation of coronary arteries
-CABG

deficiency)
-low RBC, H&H
-active bleeding

Risk for Falls

Risk for
atelectasis/
pneumonia
(prolonged bed
rest)

Acute pain

Risk for DVT

Bed sores/
pressure ulcers

-pt has unsteady gait

-pt is generally weak
-hypotensive
-altered LOC
-noncompliant to calling
assistance with ambulation

for

-difficulty breathing
-shallow breathing
-shortness of breath
-coughing
-fever
-chills
-tachycardia
-chest tightening/pain
-tachypnea
-dull percussion over affected
lobe
-diminished breath sounds from
affected lobe
-tracheal deviation
-decrease chest excursion
-decrease o2 saturation
-facial grimacing
-increased heart rate
-moaning
-restlessness
-tachycardia
-increase BP
-increase RR
-pt reports pain
-pain, swelling, and tenderness in
leg
-warm, red, skin in area of clot
-cramping at affected leg

-patient
maintaining
same
position in bed for prolong time
-skin discoloration, pain, itching,
skin loss, blisters, cavity-like
wound, tissue necrosis

-correct hypotension
-check BP before ambulating
-bed at lowest position
-side rails up
-bed alarm
-call light within reach
-remove clutter on floor
-slow postural changes
-ensure pt complies with calling for
assistance
-deep breathing
-change position every 2 hours
-coughing
-use of incentive spirometer 10 times
an hour
-encourage early ambulation as
tolerated
-maintain HOB to promote postural
drainage and ease of breathing
-prn suctioning
-antibiotic therapy
-o2 therapy
-CPAP
-chest tube
-chest xray
-do not ambulate without proper
assistance
-obtaining optimal bed position
-monitor for early signs and symptoms
of heart attack
-monitor heart 12 point ekg
-assess troponin values
-utilization of venodynes
-assessment of lower extremities (6
Ps)
-ROM as tolerated
-assist with reposition every 2 hours
-anti-coagulation therapy
-encourage early ambulation
-reposition q2h
-inspect skin, especially bony areas
-encourage ambulation if tolerated
-maintain wrinkle free linens

GI bleeding

-fatigue
-weakness
-SOB
-vomiting blood
-black tarry stools
-anemia

-adequate fluid intake

-review use of NSAIDs w/ physician
-resist urge to strain to prevent
hemorrhoids
-remain upright after eating
-H2 antagonist and proton pump
inhibitors

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).
Although I am getting more comfortable with the use of the nursing process to plan and evaluate
nursing care, there are many ways I can improve. After applying the suppository, I told the patient to
call for assistance when she feels the need to move her bowels. What happened instead was she
went to the restroom with the help of her son and told me about it after the fact. I failed to explain to
her why I wanted her to call for help. It was because I needed to assess her stool. She must have
thought it was for the sole purpose of helping her walk, in which she decided not to bother me and
just ask her son for help. I could have also told her that if she was to have her son help her to the
restroom, she could not flush so someone can assess the characteristics of the stool.
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 care plan was individualized for my patients. Patient 1 had received a spinal fusion and
laminectomy. My focus for her was neurovascular checks, pain management, fall prevention and back
precaution reinforcement. Pain management was also in a priority. Patient 2 was admitted to the
hospital with the diagnosis of hematuria and anemia. Because his troponin lab values were high I
knew I had to assess his heart sounds immediately as well as check and ask if hes experiencing
heart attack signs and symptoms. He denied signs and symptoms but had an audible beat skipping
upon auscultation. I also wanted to monitor the urine in the foley to see if the presence of blood would
be increasing or decreasing throughout the shift. Had the patient stayed on the floor I would have
monitored for new lab results and assess BUN, creatinine, troponin, RBC and H&H.
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).
My assessment skills are developing and I am being as thorough as I can be. Sometimes it may take a
while for me to listen to heart sounds. If I hear something abnormal I listen to it a lot longer to make sure
the abnormalities arent an issue with my hearing. Before reporting the abnormal heart sounds to my
instructor I was listening to the patients heart for a full minute. I know that the nurses there dont listen to
the heart for that long so I explained to the patient what I was doing and listening for. I didnt want him to
think I didnt know what I was doing.
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?
This week I administered a suppository for the first time, or at least I attempted to. I didnt realize how
slippery it would be after applying the lubrication. When my instructor inserted it she removed her finger
so I can push it in a little more. I was not quick enough and it slipped out. My instructor finished the job for

me. I was thankful for the assistance because I could only imagine how awkward the patient must have
felt having 2 sets of hands touching her rectum in front of her family. Next time I will insert and push the
suppository in all in one smooth motion without hesitation.

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 has much improved since the beginning of this clinical rotation. I can now complete
my head to toe assessment first thing in the morning. I have been able to write my DAR notes and turn
them in on time, which I had trouble with in the past. There were even times when I chose to skip lunch to
catch up on charting. If I had to care for 3 patients instead of 2, that would be a much different story. I
hope to improve my time management as more opportunities come my way.

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 not involved in making any referrals for my client. If I was the primary nurse for patient number
2 I would have requested a transfer to the telemetry unit as soon as the able normal troponin levels
were discovered. I dont understand what was going on and why they waited a full day to transfer him.
They knew about the elevated levels which is why troponin levels were pulled every 8 hours. I just
really dont see the logic in their actions. It makes no sense for something that serious to be taken so
lightly. Why would they wait for it to get even worse for them to take action?

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: Lumbar Spondylolisthesis
1. Neurovascular checks (6 Ps)
2. Reinforcement of back precaution teaching
3. dressing change and education
4. application of suppository
5. pain management
My priority for patient 1 was neurovascular checks for early detection of compartment syndrome. I
assessed her lower extremities for any paralysis, paresthesia, pain, pallor, poikilothermia, and the
presence of pulses. None were found except for a little tingling pain and numbness on her left foot which
was there before the surgery and had gotten better after the surgery. Next, I wanted to reinforcement
back precaution education. I evaluated her log rolling technique upon getting out of bed and seemed to be
very good at it. She even was telling me what to help her with and how to support her. She knew not to
bend, twist, and turn at the waist and not to carry heavy object for some time. Before discharge we
performed a dry dressing change and educated her husband on how to do it for her since she would be
unable to reach her own back. Her husband observed very closely and was thankful for the teaching.
Since the patient had not had a bowel movement for 4 days we administered a bisacodyl suppository to
treat constipation. Half an hour later she reported having a bowel movement that was brown and formed.
Pain management was also a focus with this patient because her pain level persisted at a level of 4-5 out
of 10 throughout the shift.

Patient 2: Hematuria, Anemia

1. assess and monitor for signs and symptoms of myocardial infarction
2. Assess heart sounds
3. Assess characteristics of urine in foley bag
4. safe and timely transfer to telemetry unit
My priority upon entering the patient 2s room was to assess for chest, shoulder, and/back pain, shortness
of breath, dizziness, weakness, sweating, clamming skin, and cyanosis. All of those symptoms were
either denied or absent. As I was looking over lab values before the shift begun I noticed the high troponin
levels and I was confused as to why he was still on the unit, in bed, at the far end of the hallway. After
assessing for those symptoms I listened to his heart and found an inconsistent skipping in beat. The
patient was transferred before my instructor and I had an opportunity to further assess his heart sounds.
Beside the cardiac issues, I assessed his urine because he was admitted for hematuria. The urine was
tea colored and was clear. Apparently that was a large improvement from the day prior when the urine
was the color of squid ink. My time with the patient was cut short due to him being transferred to the
telemetry unit, which I think should have happened the day before. I assisted with transferring him to the
gurney and onto his bed on the telemetry unit.