Student Name: Grace Kim

Date: 11/25/14
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

Phlebitis

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
Erythema, edema, pain, swelling,
tenderness,

DVT

Leg fatigue, pain or swelling in

legs, visible veins

Pulmonary embolism

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

Stroke

MI

Heart failure

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

Proper hand hygiene, disinfection

of hub before catheter access,
assess insertion site
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

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 a lot more comfortable with the use of the nursing process to plan and evaluate nursing
care. For example, last week, I had very few corrections/changes that I needed to make on my NCP.
This week, my found section was basically the same as my expected section. I feel that there has
been a big improvement from week 1.
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 patient
this week had an interesting diagnosis: necrotizing fasciitis. However, while infection was a big
priority, risk for DVT and breathing assessments were also important for this patient if you consider
his past and current lifestyle. He is a heavy smoker, so it was expected that his O2 sats would be a
little lower than most people. On top of that, he has high BP, which puts him at risk for conditions
affecting breathing pattern. Also, he refused to get out of bed to ambulate or use the venodyne
regularly.
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. I even noticed some redness at the patients IV site, which I brought to my nurses
attention. I also relayed to my nurses that the patient stated some numbness in his right arm, which
no one apparently knew about.
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 dont think was really able to implement a new skill this week, but I got more experience with IVPB
and subcu. I was also able to observe and assist with an attempted PICC insertion and watch the
wound nurse change the wound dressing. Even though I mostly just watched the procedures, I really
learned a lot from them and they gave me some good advice.
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 am slightly improving on my time management. Although I only had one patient this week, I
felt like I was super busy because I spent so much time with the PICC nurse and the wound nurse.
However, I did find some downtime to eat lunch! Towards the ending of the clinical days, I found
myself with not much to do.
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 client in several ways. On the first day of clinical, while I was
conducting my head to toe, I learned that my patient had some numbness in his left arm extending
from the shoulder to the fingertips. I hadnt seen anything in the patients charts about it, so I
questioned my nurse, but she did not know about it either. On the second clinical day, I noticed slight
redness around the patients IV site, and when I asked him if it was bothering him, he said that there
was some pain, so I alerted my nurse. On both days, I was looking over the recent labs and noticed
an upward trend of potassium levels. I was able to advocate with my instructor to hold his potassium
and lisinopril.

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 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 and ambulation. 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, by looking at his face
(grimacing), I could tell that he was in a lot of pain during procedures such as wound vac
dressing change and PICC insertion.
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. I noticed some redness around my
patients right foot IV site and he reported pain as well.
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.
Patient 2: