Student Name: Lisa Chee

Date: 11/19/2014
N360 Weekly Self Evaluation
WK06

1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
Patient A
Potential Complications
Respiratory depression r/t PCA use

Early Recognition
SOB, decreased RR, use of accessory
muscles, low O2 saturation, coughing,
abnormal breath sounds

Bowel perforation r/t POD #15 & 16

for ileostomy takedown, abdominal
distention, hypoactive bowels and no
BM since admission

N/V, fever, chills and severe

abdominal pain

Fatigue/ anemia

Low RBCs and H/H in lab results,

fatigue, dizziness, and bleeding,
bruising, blood in stool
Monitor for s/s infection (e.g.
drainage, redness, swelling, warmth,
pain). Monitor for elevated WBC
count in labs.
Monitor for s/s infection (e.g.
drainage, redness, swelling, warmth,
pain). Monitor for elevated WBC
count in labs.

Infection r/t to Rt brachial PICC IV

access, Lt arm peripheral IV access,
abdominal incision w/ steri strips and
NG tube
Impaired wound healing

Wound dehiscence

Wound opens spontaneously;

bleeding, pain, inflammation, fever

Falls

Impaired physical mobility r/t to age

IV Infiltration

Edema at the insertion site

Taut or stretched skin
Blanching or coolness of the skin
Slowing or stopping of the infusion
Leaking of I.V. fluid out of the
insertion site.
Redness, soreness or tenderness on
skin

IV Phlebitis

Prevention
Perform a focused respiratory
assessment, elevate HOB 30 to 45,
administer O2 supplementation per
MD orders
Perform a focused abdominal
assessment, have pt on intermittent
NG suctioning to remove excess bile
secretions, administer prophylactic
antibiotics
Ensure pt has adequate Fe in diet,
monitor O2 saturation, treat low H/H
Proper hand hygiene, maintaining
asepsis when caring for patient,
administering ABX prophylaxis as
appropriate
Encourage pt to consume a diet
containing high-protein and highcalorie to promote wound healing
(when NPO status is removed). Proper
wound care practices. Maintaining
asepsis.
Proper wound care, reduce stress on
wound, speed healing through
adequate nutrition (when NPO status
is removed), administer ABX as
ordered
Place call lights and personal items
within pts reach; encourage pt to use
call light and ask for CNA or RN for
assistance; wear non-skid socks when
ambulating; safety check: ensure
walkway is clear and free of clutter,
use of walker for assistive devices
Flush IV access prior to administer
medications, ensure IV access is
patent. Educate pt to use call light if
something does not feel right. Stop
infusion if infiltration is suspected.
Flush IV access prior to administer
medications, ensure IV access is
patent. Educate pt to use call light if
something does not feel right. Stop
infusion if phlebitis is suspected.

Patient B
Potential Complications
Ineffective breathing pattern r/t
pneumonia and COPD AEB dyspnea
and SOB w/ activity
Fatigue/ anemia

Infection r/t to Lt forearm peripheral

IV access

Early Recognition
SOB, decreased RR, use of accessory
muscles, low O2 saturation, coughing,
abnormal breath sounds
Low RBCs and H/H in lab results,
fatigue, dizziness, and bleeding,
bruising, blood in stool
Monitor for s/s infection (e.g.
drainage, redness, swelling, warmth,
pain). Monitor for elevated WBC
count in labs.
Absent BM, assess pts usual BM
pattern at home, compare with present
pattern

Prevention
Perform a focused respiratory
assessment, elevate HOB 30 to 45,
administer O2 supplementation per
MD orders
Ensure pt has adequate Fe in diet,
monitor O2 saturation, treat low H/H

IV Infiltration

SAME AS ABOVE for Patient A

Proper hand hygiene, maintaining

asepsis when caring for patient,
administering ABX prophylaxis as
appropriate
Encourage pt to ambulate, encourage
increased fluid intake, encourage
increased fiber in diet, administer
medications (e.g. miralax, docusate
sodium, bisacodyl suppository,
laxatives)
SAME AS ABOVE for Patient A

IV Phlebitis

SAME AS ABOVE for Patient A

SAME AS ABOVE for Patient A

Constipation, fecal impaction

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).
Yes, I am getting more comfortable with the use of the nursing process to plan and evaluate my nursing care.
Slight revisions were necessary. (Please refer to mini care plan for specific goals and nursing interventions).
For example, for pt A, I initially thought that he was receiving his TPN through the NG route. Utilizing the
ABC framework, I listed Risk for Aspiration as one of my top priorities for the day. However, after assessing
my pt on Day 1, I learned that he is receiving his TPN through his PICC line. Thus, utilizing the nursing
process, I revised my pts plan of care. During morning report, I learned that he has not passed gas since
admission and revised my second priority for pt A to be Risk for bowel perforation r/t POD #15 & 16 for
ileostomy takedown, abdominal distention, hypoactive bowels and no BM since admission.
In another example, for pt B, the RN caring for this pt on pre clinical day informed me that he has a h/o
noncompliance w/ medical treatment and suggested that I provided him w/ pt education on my dates of care.
After assessing my pt on Day 1, I learned that he was extremely compliant- he adhered to his medications (PO,
O2, etc) and was active in his own healthcare needs. He was cooperative w/ utilizing the sequential compression
devices while in bed and exercised his breathing w/ the incentive spirometer. Thus, utilizing the nursing
process, I revised my pts plan of care. During my head-to-toe assessment, my pt reported abdominal
discomfort. Pt further informed me that he has not had a BM in two days. His pattern of BM at home is q1-2
days. Therefore, I revised my second priority for pt B to be Constipation r/t inactivity AEB pt reports
abdominal discomfort and states "I haven't had a BM in two days".
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). Patient A
Yes. My top three priorities were to ensure 1) pt maintains an effective breathing pattern, AEB relaxed
breathing at normal rate and depth, and absence of dyspnea, cyanosis, or use of accessory muscles, 2) Pt
remains free from bowel perforation AEB absence of N/V, fever, chills and severe abdominal pain, and 3) Pt is
free from s/s infection AEB healing wound, incision clean/dry/intact, well approximated, no redness or purulent
drainage, clear breath sounds w/o cough/sputum. (please refer to mini care plan for nursing interventions).
For example, for my pts respiratory issue, my nursing interventions included: assess RR, rhythm and depth.
Monitor breathing patterns and assess for use of accessory muscles. Monitor pulse oximetry. Assess breath
sounds. Position pt with proper body alignment for optimal breathing pattern (upright, HOB elevated).
Additionally, for my pts abdominal issue, my nursing interventions included: performing a focused abdominal
assessment and administer intermittent NG suctioning to remove excess gastric secretions and to prevent bowel
perforation.
I think that my critical thinking skills are gradually improving, as compared to prior weeks of clinical.
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 think that my assessment skills are developing well. I also believe I am as thorough as I need to be. I am able
to complete my pts head-to-toe assessment in a timely manner, noting any abnormalities. I am also able to
correlate my assessment findings w/ my primary RNs findings. This week, I had extra practice conducting
focused respiratory assessments because both pts had respiratory issues- one was related to PCA use, and the
other was related to h/o COPD..
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?
A new skill I implemented this week was NG intermittent suctioning. I learned how to work the dials on the
wall suction, as well as connect/ disconnect the tubing from the wall suction when my pt wanted to ambulate in
the hall. I learned how to note/ describe/ discard/ document the gastric contents in the suctioning chamber. Yes,

I asked my nurse aid to teach me how to disconnect the tubing and asked my clinical instructor for help with
operating the wall suction and describing the gastric content.
One of my pts this week (patient B) had several respiratory treatments on day 1 of pt care. I was able to
observe the respiratory therapy team administer his nebulizer treatments. He was discontinued from the
nebulizer treatments on day 2 of pt care.
Additionally, I gained additional practice with hanging IVPB. I believe I performed the skill well, with the
exception of remembering to place a trash can nearby when I am priming the IV line! Other than that, I was able
to hang three IVPBs this week. I was also efficient in monitoring the infusions and promptly informed my
primary RN when the infusion was complete and ready to be saline-locked.
Lastly, I also worked on my effective communication skills this week. I was efficient with updating my team
leader (to update my clinical instructor, if I was unable to locate her), primary RN, covering RN and nurse aid. I
was also able to communicate effectively with my patient regarding his morning medications, why his blood
pressure medications were held, and encouraged my pt to use his incentive spirometer and sequential
compression devices. However, there was one miscommunication that occurred during this week. I relayed the
wrong information to my clinical instructor regarding the route of my pts TPN infusion. However, I ensured to
update my clinical instructor of my communication error and informed her of the correct route of TPN infusion,
which was through my pts PICC line.
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?
This week, managed care for two patients on both clinical days. I believe that my time management skills went
well. I was able to prioritize my care for both patients efficiently and effectively. For example, on day 1, I
learned in morning report that my patient would be having a CT scan later in the day, but the exact time was
unknown. He was NPO d/t his ileostomy takedown procedure and (-) for flatus post procedure. Thus, I ensured
to assist my pt with his ADLs and completed his head-to-toe assessment prior to him leaving for his CT scan at
around 0835. Because pt A went to his CT scan appt, I was also able to assist my nurse aid with ADLs for pt B.
Because both pts were relatively stable, I was able to go above and beyond what was expected and assisted
with I&Os for both patients. On day one of pt care, I had my team leader assist me with ADLs, which was also
an effective method of time management, because the bed baths/ sheet changes got done a lot quicker. Although
I had to care for two patients, I was still able to submit my DAR notes by the 1100 deadline to my clinical
instructor and documented them into the hard chart in a timely manner.
On day 2 of patient care, I was extremely busy. Between patient A and patient B, my clinical instructor,
colleagues and I had a total of 4 IVPBs to administer. I managed my time efficiently by ensuring that I had the
medications, supplies and drip rate calculations ready prior to seeking my clinical instructor. Additionally, I
rounded on my patients periodically to monitor my pts IV site for infiltration/phlebitis and when the infusion
was completed (to ensure the line does not run dry).
7. Was I involved in making referrals for my client in any way? How could the nursing role in
this process have been strengthened?
No, I was not involved in making referrals for my client in anyway. However, for patient B, I learned from
morning report that he had requested a desaturation study, so he could be discharged home without O2 therapy.
Thus, at the end of shift report, I reinforced my pts desires to my primary RN to ensure that a follow up was
made and that the pt can somehow get his desaturation studies completed ASAP.

8. List the specific interventions, in order of priority, for your clients and explain how you
determined which interventions took precedent.
Patient A:
1. Conduct a focused respiratory assessment , elevate HOB at least 30 to 45 degrees
a. Pt is at risk for respiratory depression r/t PCA use. Maintaining ABC is #1 priority!
2. Conduct a focused abdominal assessment
a. Pt is at risk for bowel perforation r/t POD #15 & 16 for ileostomy takedown, abdominal distention,
hypoactive bowels and no BM since admission
3. Assess pt for s/s of anemia
a. Pt has low RBC and H/H labs.
b. Pt is at risk for bleeding and bruising.
c. Pt is at risk for fatigue and dizziness, possibly leading to falls.
4. Encourage pt to to utilize sequential compression devices while in bed. Encourage pt to ambulate, as
tolerated. Administer scheduled doses of heparin.
a. DVT/PE prophylaxis
5. Assess PICC line, peripheral IV site, abdominal wound NG site for redness, swelling, warmth, pain.
a. Pt is at risk for infection, a possible complication would be sepsis.
6. Maintain asespsis and proper hand hygiene. Administer ABX as prescribed.
a. Pt is at risk for infection, a possible complication would be sepsis
7. Fall prevention, assist with ambulation
a. Pt is at risk for falls r/t age
Patient B:
1. Conduct a focused respiratory assessment , encourage pt to utilize incentive spirometer, elevate HOB at
least 30 to 45 degrees, administer O2 via NC
a. Pt is at risk for respiratory depression AEB SOB and dyspnea w/ activity, and low RBC, H/H labs.
Maintaining ABC is #1 priority!
2. Assess pt for s/s of anemia
a. Pt has low RBC and H/H labs.
b. Pt is at risk for bleeding and bruising.
c. Pt is at risk for fatigue and dizziness, possibly leading to falls.
3. Encourage pt to utilize sequential compression devices while in bed. Encourage pt to ambulate, as
tolerated.
a. DVT/PE prophylaxis
4. Assess peripheral IV line for redness, swelling, warmth, pain.
a. Pt is at risk for infection, a possible complication would be sepsis.
5. Maintain asespsis and proper hand hygiene. Administer ABX as prescribed.
a. Pt is at risk for infection, a possible complication would be sepsis
6. Administer laxative
a. Pt at risk for constipation. Complications include hemorrhoids and fecal impaction.