Student Name ______Karissa Higa______
Date _______4/11/14______Week 5________
N360 Weekly Self Evaluation
1. Considering your patients current status, list potential complications and strategies for
prevention and early recognition.
Complications
Hypoxia
Fatigue from interrupted sleep
Permanent narrowing of
bronchial tubes
Deep Vein Thrombosis
Infection
Hyperglycemia
Prevention
Assess lung function
O2 status- pulse oximetry
Avoid triggers
Educate on how to prevent
attacks- use AC, frequently
clean house, clean home
décor to decrease dust, cover
up face and nose when its
cold, control GERD, hardwood
floors, exercise, proper
nutrition, stop smoking
Take prescribed medications
Take prescribed medications
Get vaccinated
Identify triggers
Treat symptoms early
Monitor breathing
Leg compression device
Get pt. out of bed and
increase mobility
ROM exercises
Administer prescribed
anticoagulants
Good hand hygiene
Proper wound care
Inspect sight and assess for
signs of infection.
Administer scheduled
antibiotics.
Check blood glucose before
meals and at night
Administer correct amount of
insulin
Assess for signs of
hyperglycemia
Limit sugar intake
Take prescribed medications
Early Recognition
Pulse oximetry reading <90%
SOB
Waking up in middle of night
with shortness of breath
Dizziness
HA
Tachycardia
Tachypnea
High BP
Waking up with SOB
Tachypnea
Tachycardia
Sweating
SOB
Chest tightness
Anxiety
Swelling, usually in the leg,
ankle or foot
Pain
Warmth, redness, pallor, or
cyanotic skin.
Redness at site
Swelling
Pain
Tenderness
Fever
Chills
Warmth
Purulent discharge
Hot, dry skin
Polydipsia
Polyphagia
Polyuria
Hypoglycemia
Hypothermia
Pain at surgical site
Respiratory Depression r/t
PCA
Compartment Syndrome
Constipation
as ordered
Educate pt on symptoms of
hyperglycemia
Educate on correct insulin
administration
Check blood glucose before
meals and at night
Administer correct amount of
insulin
Assess for signs of
hypoglycemia
Ensure meals are eaten after
insulin administration
Educate pt on symptoms of
hypoglycemia
Don’t drink alcohol or smoke
out in cold
Protect body from cold by
wearing gloves, layered
clothing, two pairs of socks,
scarf, and/or hat
Avoid cold weather with high
winds and wet clothes
Educate on PCA use, report
pain to the nurse
Premedicate pt w/ pain meds
before therapy or getting OOB
Support surgical limb when
turning or moving pt.
Apply ice pack
Provided non-pharmocological
pain relieving methods
Check PCA machine to make
sure settings are correct
Assess respiratory status of pt
Educate family that only the pt
should be pushing the button
Educate pt on how to use
PCA and its side effects
Adjust dose as needed, as
ordered by physician.
Assess pain level
CMS check
Assess skin color below
surgical site and around
Assess perfusion below site
Call MD if pain medications do
not alleviate pain
Encourage fluids and mobility
Tachycardia
Irritable
Restless
Polyphagia
Diaphoresis
Cool, clammy skin
Depression
Blurred vision
Seizure
Coma
Shivering
Shallow, slow breathing
Confusion
Drowsiness
Slurred speech
Pale, cool skin
Slow, weak pulse
Arrhythmias
Heart failure
Pt verbally announces pain
Non verbal cues: grimacing,
guarding site with hands,
tachypnea, tachycardia,
wincing, restless, crying,
combative.
Slow breathing <12
breaths/min
Decreased LOC
Shallow breaths
Confusion
Cyanosis
Weakness
Increased pain, medications
do not help
Decreased sensation
Numbness/tingling
Pale skin
Weakness
Distended abdomen
Increase fiber in diet
Administer stool softeners and
laxatives (if needed)
Assess bowel sounds,
palpate, and shape of
abdomen
No BM in last 3 days
Abdominal discomfort or pain
Feeling that you can’t
completely empty rectum
Straining to have a BM
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. It is the 5th week and I feel comfortable with the nursing process. I am able to create a
mini care plan specific to my patients and implement them in my care. I am also able to
adapt to any given changes my patient may have. For example, my first pt was admitted for
respiratory problems but I ended up focusing on his blood sugar level and his body
temperature. I was able to change my focused assessment to monitoring for hyper or
hypoglycemia and preventing further hypothermia.
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).
Yes, however like I stated before the situation changed but I was ready to adapt. I went in
thinking I was going to focus on his respiratory status but ended up focusing on his diabetes
and hypothermia. I made sure he wasn't showing any signs of hypoglycemia or
hypothermia. I also continued to monitor his temperature and status throughout the day.
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 I am getting used to all my assessments. As I keep doing my head to toe every week
I seem to be getting better and it is becoming easier to perform. I also have been feeling
comfortable doing my focused assessments like respiratory status, wound assessment, or
looking for any signs of infection.
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 got to work with a hypothermia patient whose temperature was 35C. I managed my time
well and did frequent checks on his temperature. I made sure to keep him warm and by the
end of my shift his temperature was going back up.
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 thought my time management was good. I was able to finish all my medications
and give a bed bath to my patient. I also had to feed him his meals and clean him up when
he soiled his briefs. I also finished my dressing change on time. Working with two patients
kept me busy but I was still able to finish on time and do CNA tasks.
7. Was I involved in making referrals for my client in any way? How could the nursing role in
this process have been strengthened?
This week I worked with a patient whose primary language wasn't English. However, the
primary nurse spoke the same language and we got a little response out of him. The nurse
explained to him what was going on and asked about any pain, SOB, etc. I also made a
referral for my second patient to the primary nurse who then called the doctor. He had an
issue about the PCA function and I told my nurse about his problem, who was also informed
by the night shift nurse. At the end of my shift I reminded my nurse about the problem and
I’m hoping she ordered a new pump.
8. List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.

Assess breathing pattern, vital signs, signs of hyper or hypoglycemia, hypothermia,
check labs, assess IV site, assess mittens to ensure proper circulation, assess heel
ulcer, and assess butt excoriation.
 Head to toe assessment, pain (use FACES)
 Report any changes to primary nurse and instructor
 Administer prescribed medications
 Repositions q2h
 Heel dressing change
 Monitor glucose level and temperature
 Provide warming measures if needed- extra blankets, towel over head and around
neck, or get order for bear hug.
Focused assessments are always priority for me because that is the reason why the patient has
been admitted in the first place. I want to make sure there are no complications going on caused
by the primary diagnosis. Then I want to go ahead and finish up my head to toe assessment to
get an idea of the patient’s overall status. Next I want to report any changes to my instructor and
nurse to keep the both updated. After all my assessments I can evaluate if it is proper to
administer all medications (check blood pressure and pulse before giving blood pressure
medications). After medications and can do the dressing change and assess the wound site.
Lastly, I want to monitor my patient for any acute changes and take the proper action if
complications do arise.

CMS check, surgical site assessment, pain level, respiratory status, mobility, and assess
IV site.
 Check PCA machine to make sure it is working properly and set at the correct dose.
 Head to toe assessment
 Report changes to primary RN
 Administer prescribed medication
 Encourage IS use
 Administer prn medications if needed
I always do assessments first to get a better picture of what my patient looks like now so I can
plan my day accordingly. I can read the charts but it won’t give me an updated picture of how
the patient is today. After assessments I can give the proper medications, making sure it is safe
to administer. After that I can encourage my patient to use the IS to prevent pneumonia and get
OOB, if tolerable, to prevent constipation and promote a quicker recovery. If his pain persisted I
could have given him prn medication, but pt refused when asked.