Katherine Casey

NURS 360
3/15/16
Week 2 Self-Reflection
1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
This week I worked with a dementia patient that was A+Ox0, confused, mute, and NPO.
Due to this, my patient was at major risk for falls and aspiration. The interventions I performed to
decrease her risk of falling included assessing every hour that her bed alarm was on, her fall risk
band was around her wrist, her fall risk sign was hanging above her bed, her call light was within
reach, and her bed was in its lowest position before I exited her room. The interventions I
performed to prevent my patient from aspirating included assessing every hour that her NPO sign
was also hanging above her bed and ensuring no food or drinks were in her room or any other
items that could cause aspiration were within reach.
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).
In comparison to last weeks clinical, Ive shown significant improvement in my ability to
use and implement the nursing process. In the previous reflection, the main component of the
nursing process I talked about needing to improve upon was the assessment part of the process,
specifically in regards to becoming more meticulous of my patients surroundings. This includes
making sure to assess for any devices at the bedside and the expiration dates of any IV fluids or
tubing present in the room, regardless of whether the patient is hooked up to a pump or not. Its
important for nurses to remember to do these checks when they first enter a patients room so
that they do not have to return shortly after to reassess something.
During the first week of clinical, I wrote about how I was unaware of a bair hugger
machine in my patients room due to not knowing what one looked like and thought it was just
apart of her bed. She was also not hooked up to a pump so I did not initially check the expiration
date on her IV piggyback tubing until I began gathering the needed supplies to administer that
medication to her an hour later. After these two situations occurred, I decided to create a list of all
of the necessary things to check for when I first go to assess a patient and this greatly improved
the thoroughness of my assessments this week and allowed me to be more time efficient as well.
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 plan of care was individualized for my patient in a couple of ways. For the first way, I
made sure to check my patient more than just once every hour because of the fact that she was
disoriented, confused, and a major fall/aspiration risk. She was also on a 2-hour turning schedule,
but my patient favored lying on her left side and would return to that side if I tried turning her the
other way. Due to this, I had to adjust where I positioned her cushions/pillows and I had to assess
her skin more carefully for areas of redness as well.
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).
As Ive mentioned earlier, assessment skills have been continuing to improve from week
to week and I was able to remember to assess for everything that I usually forget to do initially.
One thing I had trouble with this week was listening to my patients breath sounds and heart
sounds. It was hard for me to hear both of these things and I had to get a second opinion to see
whether or not it was just me because of the fact that I have diagnosed hearing loss in my left ear.
After talking to my nurse about this, she confirmed that my patient had diminished breath sounds

in both of her lower lobes and that her heart rate was soft as well. I think my judgment needs
improvement, but I believe this will get better with more experience and exposure.
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 did not perform any new skills, but I was able to administer one IV piggyback
medication. When it comes to evaluating my performance, it was definitely not my best and I have
definitely performed this skill a lot better in the past. I think what partially caused me to not do my
best was that I started coming down with a cold that day, which progressed to body aches and an
infection later on that week. In general though, I feel I still need to get more comfortable with
working with IV lines/administering piggyback medications and learning how to hold these things
in my hands smoothly. My plan for improvement is to select patients in the future who have a lot
of IV medications to administer so that Im able to gain more practice in this area.
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 I had no problems with time management, but I also only had one patient to
care for, which definitely made it a lot easier. Some of my time management strategies I used this
week though included charting in my patients room after I completed a task and using my brain
that has a time schedule on the side of it/referring to it frequently throughout my shift. I think when
I get assigned to two or more patients at a time though, I am going to start trying to administer
medications/perform skills an hour before they are due or just before they are due so I am not
playing catch up or putting myself at risk for that in case something happens that I need to remain
with a patient longer than intended.
7. Was I involved in making referrals for my client in any way? How could the nursing role in this
process have been strengthened?
When I would turn my patient, she again favored lying on her left side and seemed in
pain when she was moved away from that position as evidenced by facial grimacing, vocalization,
and her being resistant. She wasnt receiving any pain medications and due to the fact that she
needed to be turned frequently for brief changes, showers, and every 2 hours for position
changes, it may have been beneficial for her to receive some form of pharmacologic intervention.
I talked to her nurse that I believe she was in pain, but I could have stressed more about my
concern about the need to improve managing it and been a better patient advocate.
8. List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.
For my patient, the interventions I performed for her in order of importance included 1) vitals,
a thorough initial Head-To-Toe assessment, and administering her scheduled IV piggyback
medication at the designated time, 2) rounding multiple times every hour to ensure the patients
safety, which included checking her bed alarm/environment, and 3) turning my patient every 2 hours
to prevent bedsores and providing brief changes as soon as possible after my patient voided. The
interventions listed under #1 were the most important because they dictate the plan of care for the
remainder of the shift/are needed to determine the patients acuity. For the other interventions, if my
patient wasnt confused and disoriented, #2 and #3 would have been switched. Since she did have
cognitive impairment though and was a major fall/aspiration risk, frequent rounding took precedent
over the remaining interventions.
9. Did I anticipate consequences of my nursing interventions? (Describe).

For one of the times my patient was scheduled to be turned, I decided not to because she was
resting, the fact that she would always try to resist being turned, and because it caused her pain. Her
nurse agreed, but this increases the risk of my patient developing a bedsore over time, especially if other
caretakers decide to do the same.
When it comes to not advocating more for something to be done regarding if she could benefit
from receiving pain medications, possible consequences of my lack of better advocacy include the patient
developing mistrust towards the hospital staff, her trying to resist more aggressively, and her pain
worsening/causing her significant discomfort. I wish I asked more questions about how I could have
helped to improve her pain or what types of other interventions the hospital staff could do/have explored.
In addition, if she received pain medication, it would help to improve her feelings towards the staff and
decrease her wanting to resist position changes.