Student Name Aja Elmore

Date 11/9/16
N360 Weekly Self Evaluation

1.

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

Potential
Complication
s
GI Bleed
Fluid volume
deficiency

Risk for
imbalanced
nutrition

Early
Recognition

Prevention

-decreased skin turgor

-dry mucous
membranes, thirst
-sudden weight loss
of 2% or greater
-postural hypotension
and/or low B/P
-weak, rapid pulse
-neck veins flat when
client is supine
-change in mental
status
-elevated BUN and
Hct
-decrease in urine
output with increased
specific
gravity
(reflects an actual
rather than a potential
fluid volume deficit).
-Abdominal pain with
or without pathology
-Actual or potential
metabolic needs in
excess of intake with
weight loss
-Capillary fragility
-Decreased serum
albumin
-Decreased serum
transferrin or ironbinding capacity
-Diarrhea and/or
steatorhea
-Documented
inadequate caloric
intake
-Dry, brittle, hair
easily plucked from
scalp
-Excessive hair loss
-Hyperactive bowel
sounds
-Loss of
subcutaneous tissue
-Loss of weight or
without adequate
caloric intake
-Mental irritability or
confusion
-Muscle weakness
and tenderness
-Pale, dry skin
-Paresthesias
-Poor muscle tone
-Red, swollen oral

-Implement measures to prevent or treat fluid volume deficit:

-perform actions to reduce nausea and vomiting if present
-perform actions to control diarrhea if present (e.g. consult physician about another
antimicrobial agent if onset of diarrhea seems related to initiation of antimicrobial therapy,
administer prescribed antidiarrheal agents)
-perform actions to reduce fever in order to reduce insensible fluid loss associated with
diaphoresis and hyperventilation
maintain a fluid intake of at least 2500 ml/day unless contraindicated; if oral intake is
inadequate or contraindicated, maintain intravenous fluid therapy as ordered.

Maintain accurate I&O, monitor lab results relevant to fluid retention, monitor skin turgor,
monitor for nausea and vomiting.

Activity
intolerance

Risk for
bleeding

Risk for falls

Risk for
infection

Deficient
knowledge

mucous membranes
-Sunken fontanel in
infant
-The individual who
is not NPO reports or
is found to have food
intake less than the
recommended daily
allowance (RDA)
with or without
weight loss
-Triceps skinfold,
mid-arm
circumference, and
mid-arm muscle
circumference less
than 60% standard
measurement
-Weight 10% to 20%
below ideal body
weight and height
-Verbal report of
fatigue or weakness
-Inability to complete
desired activities
-Abnormal HR, BP,
or
respiratory
response to activity
-Exertional
discomfort
or
dyspnea

-Restlessness and
anxiety
-tachycardia
-diminished CO,
dropping venous
pressures
-tachypnea
-SOB
-Reduction in urine
output
-Blood in stool
-patient is
hypotensive and was
unable to do PT due
to orthostatic
hypotension
-Assess for Severe
abdominal pain.
-Chills.
-Fever.
-Nausea.
-Vomiting.

-Lack of questions
-Verbalized
misconceptions

-Assess the patients level of physical activity and mobility

-Assess nutritional status
-Assess the need for ambulation aids: bracing, cane, walker, equipment modification for
ADLs
-Assess baseline cardiopulmonary status before initiating activity using HR and orthostatic
BP changes
-Observe and document response to activity. Signs of abnormal responses to be reported
include the following: increased HR of 20 to 30 beats/min over resting rate, or 120 beats/min;
palpitations/noticeable change in heart rhythm, significant increase in systolic BP, significant
decrease in systolic BP; dyspnea, labored breathing, wheezing; excessive weakness, fatigue;
light-headedness, dizziness, pallor, diaphoresis; chest discomfort
-Assist with ADLs as indicated; however, avoid patient dependency as much as possible
-encourage physical activity consistent with patients energy resources
-Encourage active ROM exercises. Encourage the patient to choose activities that gradually
build endurance. If further reconditioning is needed, confer with rehabilitation personnel
-Monitor coagulation levels
-Obtain thorough medication history
-Monitor stool characteristics

-Bed at lowest position

-tell the patient to call for assistance to bathroom
-call light and belongings in reach
-Slow OOB/ position changes
-Treat orthostatic BP
Know risk factors for the patient:
-advanced age
-existing bowel disease
-bleeding complications
-malnutrition
-the nature of the original cause of the condition
-smoking
-alcohol or drug abuse
-active treatment for cancer
-conditions requiring steroids or biologic agents including lupus, rheumatoid arthritis, and
similar conditions.
other medical conditions such as heart disease, kidney or liver problems, and emphysema.
-Instruct the patient to alert staff if experiencing sudden abdominal pain
-Assess the patients understanding of the cause and treatment of GI bleed
-Assess the patients understanding of the need for long-term follow-up and possible lifestyle
changes
-Explain the procedures necessary for diagnosis or treatment before they are performed
-teach the patient the dose, administration schedule, expected actions, and possible adverse

effects of medications that may be prescribed for long periods.

2.

List the specific interventions, in order of priority, for two of your clients and explain how you determined
which interventions took precedent.

Patient 1: Resolved GI bleed

1. Check labs (hemoglobin, hematocrit). I did this first to determine if the patient was anemic to
determine the specific complications I needed to monitor for.
2. Check vital signs. I did this to compare to baseline and determine if there were any acute changes
(signs of infection, etc). This patient had high blood pressure so I needed to check trends and report to
the nurse for med admin.
3. Physical assessment
a. Abdominal assessment. I did this next because the patient had an endoscopy on the day before
for GI bleed.
b. Abdominal sounds and distention if present. I did this next on the head to toe since the patient
had a GI procedure performed and could be at risk for infection if the mucosa perforated.
c. Peripheries
d. IV site. I did this next on the assessment because his other IV infiltrated the day before. He
was also scheduled to receive an IVPB.
e. Pain assessment. I did this last on my assessment because the patient denied pain in his
abdomen, however he had pain behind his knee
f. I reported off this finding of pain to the nurse after assessing the area for signs of DVT. The
patient wasnt a high risk for forming DVT because he was mobile and active and had the
pain prior to being admitted to the hospital.
4. Administer medications. I did this next because it was time to give the meds and because the patient
had blood pressure medication. I needed to check the blood pressure and heart rate prior to giving it for
safe administration. The blood pressure medication would be contraindicated if the patient were
actively bleeding, as it could cause extensive hypotension.
5. Monitor for SE of meds. I did this next because the patient just received blood pressure meds and I
wanted to make sure that they were working. I also wanted to ensure that he was safe and prevent
complications including falls since the patient liked to get up to walk every hour.
6. Report off any changes throughout shift
Maintain safety at all hourly blood pressure checks and hourly rounding (fall prevention)