Student Name: Grace Kim

Date: 10/31/14
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

Perforation

Sepsis

Tissue death

Reoccurance

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
Severe abdominal pain, vomiting,
chills, fever, nausea

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
Abdominal pain, N/V, bloating,
frequent loose stools and flatus,
hyperactive bowel sounds

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

Diet changes, IV fluids, electrolyte

replacement, treat underlying cause
Contact
PCP
for
continuous
abdominal pain, early recognition
and treatment of bowel obstruction,
NGT
suctioning
of
abdominal
contents, remaining NPO status
Prevention of bowel perforation

Prevention of bowel
leading to sepsis

perforation,

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)

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).
This was only my second week at clinical, so I feel that I still have some problems with using the
nursing process to prioritize my plan of care. Although I am able to identify the necessary nursing
interventions needed, sometimes I need some help from my instructor.
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 diagnosis and plan of care were definitely individualized for my patients. For example, my
first patients nursing diagnoses (NANDA) were pain r/t bowel obstruction, and risk of perforation
(worsening of SBO), while my second patients nursing diagnoses were risk for infection, risk for falls,
and pain. Once in a while I do have some difficulty in this area as mentioned previously.
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 much better now as compared to the first week. I was so rusty,
with being out of med/surg for a year. However, there is still room for improvement. I should probably
be getting a lot faster at performing head to toes, although I felt that I was pretty thorough in my
assessments this week.

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 so excited that I finally got to do something this week. Although it wasnt much, I D/Cd a saline
lock and administered a subcu. I also emptied a colostomy bag; Id never seen an ostomy before this
week. That wasnt really a skill but it was neat to finally see an ostomy. I think that I did pretty well
with the skills that I was able to do. I am hoping that next week I will get to do more.
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 feel that my time management is okay, considering that I am also doing CNA skills. Once in a while,
I find myself with nothing to do, so I try to help out my classmates. It would be fun to see how I
manage with 2 patients at the same time.
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 dont think I was able to be involved with making any referrals for my patients this week. The closest
I got to this was trying to advocate for my patient when he kept complaining of excruciating pain.
However, the nurses did not feel the need to call the doctor.
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 and monitor patient tolerance to advancing diet. This was my priority because my
patients diet orders were changed from clear liquids to full liquids for breakfast just a few hours
before my shift. He was then advanced to soft regular for lunch.
2. Monitor patient blood pressure. This was my second priority because my patients blood
pressure had been trending on the higher side since he was admitted to the unit. He also had a
PRN order for Nitropaste for BP>160.
3. Discharge teaching. This was my third priority because the doctor stopped by around noon and
told my patient that he would discharge him that day if he could tolerate soft food for lunch.
4. Assess pain level and characteristics. This was my last priority because my patient was not
really in any pain at this point and was already ready to go home.
etc...

Patient 2:
1. Perform focused assessment on affected extremity. This was my priority intervention
because my patient was postop day 2. I wanted to assess CMS and for any S&S of infection.
2. Assess pain level and characteristics. This was my second priority because my patient was
post-op day 2 and complaining of excruciating pain 10/10 unrelieved by medication.
3. Anticipate need for pain relief. This was my third priority because my patient had PT
scheduled, and if he were in pain, he would be less willing to participate.
4. Assist patient with ambulation (not by myself). This was a priority because my patient had a
TKA. My patient hadnt gotten out of bed since the surgery. There was almost a fall incident
when he wanted to go to the bathroom.
5. Assess environment for factors known to increase fall risk. This was also a priority because
my patient was at a high risk for falls.
6. Place items used by patient within easy reach. This was a priority because my patient had
limited ROM.
7. Assess patients ability to perform ADLs effectively and safely. This was important because
my patient had limited ROM.