Student Name _Sun Young Helmer

1.

Date _November 14, 2014

N360 Weekly Self Evaluation

Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
PATIENT 1

Potential Complications

Early Recognition

Prevention

High Blood Pressure

Headache, N/V, dizziness, blurred

vision

Sepsis

Rapid breathing, change in mental

status, fever, shaking chills, low
body
temperature,
decreased
urination
N/V, fatigue and weakness, change
in urine output, muscle cramps,
confusion
Fever, increased WBC, chills,
shivering, rigors; surgical site:
inflammation, swelling, redness,
drainages
Risk factors: age, orthostatic
hypotension, medication such as
antihypertensive meds, disturbed
balance or co-ordination, muscle
weakness

Monitor s/s of high blood pressure,

Administer medications
(antihypertensive medicine)
Monitor lab value such as WBC,
prevent
infection,
antibiotic
medication

Kidney damage

Infection

Falls

Potential Complications
Constipation

Hypovolemia (diverticulitis can

cause internal bleeding)

Atelectasis

Venous thromboembolism
Infection

Bleeding

PATIENT 2
Early Recognition
Nausea, abdominal pain, passing
hard and dry stools, straining or pain
during
bowel
movements,
experiencing a rectal blockage
Hypotension, anxiety, dizziness,
blue lips and fingernails, rapid heart
rate, weak pulse, low or no urine
output, loss of consciousness
Cough, chest pain, breathing
difficulty, low oxygen saturation,
cyanosis, tachycardia
Swelling in legs, tenderness, pain,
erythema, leg fatigue
Fever, increased WBC, chills,
shivering, rigors; surgical site:
inflammation, swelling, redness,
drainages
Headache, dizziness, fatigue, pale
skin, confusion, heart palpitation,
fever, rapid pulse

Monitor lab values such

creatinine and BUN, treat HTN

as

Monitor VS change including lab

results (WBC), practice good hand
hygiene.
Reviewing medication, improving
management of any medical
condition, assist ambulation of the
pt., educate use of an assistive
device, help the pt. to use bed
commode, keep the bed in the lowest
position

Prevention
Encourage the pt. to exercise and
drink adequate fluid, administer
stool softener
Monitor lab value; H & H, assess
VS and dizziness. Assess urine
output, respiration, LOC
Assess
respiratory
difficulties,
perform
intensive
spirometer
frequently
Elevate the legs, SCDs, ultra sound
order to evaluate DVT present.
Monitor VS change including lab
results, assess incision site carefully,
good hand hygiene.
Assess surgical site, including
monitoring lab value; H & H
Check platelet, PT,PTT, INR of the
patient to evaluate risk of bleeding.

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 had two patients to take care of in this week. Initially I chose the patient with diverticulosis as my primary
patient. However, I decided to take care of another patient who had UTI as my primary patient because the
patient with UTI needed more nursing care and interventions. I planned the day in advance and prioritized my
nursing care for the patients.

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).
One of my nursing diagnoses for the patient with UTI was hypertension knowledge deficit related to lack of
information about the disease process and self-care. The patient had an episode of high blood pressure (180/80)
during the morning shift. I assessed the s/s of high blood pressure. For example, I asked the patient about
headache, dizziness, N/V, and vision changes. Also, I rechecked BP a couple of times for the accuracy of the
result. I administered antihypertensive medication and recheck the patients BP after. I explained about the
medication and educated the patient about the importance of medication compliance in hypertension.

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).
My patient has hx of HTN. During the morning VS check, I noticed that high BP that was not normal for the
patient. I checked the patients base line through the electronic chart. Also, I rechecked the patients BP for
accuracy of the result. I assessed the patient to identify s/s of high blood pressure. I asked the patient about
headache, N/V, dizziness, and change in vision. Also, I observed the patients gait during assisting the patient
moving from the bed to the chair. I assessed any change of the patient during this position changes. The patient
denies any of s/s of high blood pressure. However, I developed a nursing intervention to assess the patients
knowledge of the antihypertensive medication. Also, I educated the patient about what to report to nurses to
prevent hypertensive crisis.

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?
In this week, I had an opportunity to assess the patients knowledge of the disease (hypertension) and educate
the patient about antihypertensive medications. For example, I educated the patient about possible
complications of HTN and the importance of compliance of medications. While I administering patients
medications, I explained about the medication. I can improve this by learning about medications that the patient
takes and focusing on pathophysiology of the patients diseases.

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?

7.

8.

This was the first week I took care of two patients in one day. I had very busy day because my primary patient
needed frequent nursing care. My primary patient had to use bedpan almost every hour (the patient had UTI). I
had to administer medications for both patients and it was hard for me to manage time. I learned that prioritizing
of nursing task is very important to improve my time management. For example, my primary patient had high
blood pressure (180/80) so I gave an antihypertensive medication first for the patient. Afterwards I took care of
second patient.
Was I involved in making referrals for my client in any way? How could the nursing role in this process
have been strengthened?
No. However, I communicated with the PT technicians about the pt.s current high BP. One of nursing roles of
making referrals is communicating with interdisciplinary medical team. Also, I educated the patient about s/s of
high blood pressure.
List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.

Patient 1: The pt. was admitted to the hospital due to fall and UTI
1. Monitor intake and output to determine if fluid replacement therapy is adequate
a. Treatment of urinary tract infection is increased fluid intake
b. The pt. has hypertension; it is important to monitor UOP to check renal function and edema
2. Monitor urine color changes, voiding pattern
a. The pt. has UTI (frequency, urgency and hesitancy)
3. Monitor VS; assess s/s of high blood pressure (e.g. headache, N/V, dizziness, blurred vision..)
a. The patient has HTN; the patient is risk at stroke, renal injury, and hypertensive retinopathy
b. Administer medication (anti-hypertensive) as prescribed
4. Monitor vital signs to detect fever and increased stress on kidneys
a. Fever is one of signs and symptoms of infection
b. The pt. at risk for elevated blood pressure due to complication of UTI (Kidney involves in
BP)
5. Prevention of falls
a. The pt. is at risk for falls related to age and weakness
b. Instruct the pt. about proper way to ambulate; use of assistive devices
6. Assess orientation and alertness
a. The pt. is at risk for falls
b. Reorient the patient frequently
7. Encourage the patient to urinate and drink as much as possible; provide pericare after voiding
a. The pt. has UTI
8. Educate the patient about antihypertensive medications along with their rationale, dosage, expected and
adverse side effects.
a. The patient has knowledge deficit of hypertension related to lack of information and self-care
b. The patient reported non-compliance with antihypertensive medication
c. The patient is at risk for hypertensive crisis

Patient 1: The pt. had a surgery of laparoscopic sigmoid resection.

1.

2.
3.
4.
5.
6.
7.
8.

Conduct a focused respiratory assessment

a. The pt. has a hx of COPD
b. PCA use for pain
Focused GI assessment
a. The pt. is risk for constipation due to abdominal surgery
Assess surgery incision site for color, integrity, any S&S of infection
a. The pt. is at high risk of infection
Monitor VS; presence of chills, fever, change in mentation
a. The patient is on post op day # 4 of laparoscopic sigmoid resection
Monitor intake and output
a. To assess kidney function
Monitor pain
a. Assess pain due to surgery
Educate the use of incentive spirometer
a. The pt. is at risk for atelectasis and pneumonia
Prevention of falls
a. The pt. is at risk for falls due to weakness from surgery
b. Assist the patient with ambulation