Student Name: Van Mai

Date: 11/13/16

N360 Weekly Self Evaluation

1. Considering your patients current status, list potential complications and
strategies for prevention and early recognition.
#69. Dx: Left open tibia and fibia type I, II fracture. Left femur Fx.
Right close tibia and fibia fx.
Potential
complicatio
ns
Acute pain
related
surgical
wound and
bone
fractures.

Strategies for prevention

Early recognition

- Determine pain quality, severity,

- Pt. reports pain
location, onset, duration, and
- Non-verbal signs of
precipitating and alleviating factors.
pain
- Monitor VS
- Activity intolerance
- Administer pain medications
- Provide times for rest
- Respond immediately to c/o pain
- Evaluate patients response to pain
medications within 30 minutes.
- Notify primary nurse if interventions are
unsuccessful or if current complain is a
significant change from the patients past
experience of pain.
- Encourage patient to use nonpharmaceutical pain management
techniques such as meditation,
imagination and distraction by TV or
music.
- Carefully lift and support the extremities
when reposition.

Potential
complicatio
ns

Strategies for prevention

Early recognition

Bleeding
- Assess symptoms of unusual bleeding,
secondary to skin for bruises, hematomas.
surgery and - Assess wound and dressing for drainage,
injuries.
stool and urine color and skin for bruises.
Report increased drainage.
- Monitor VS, level of energy, platelet and
coagulation test results
- Monitor CBC, Hgb, Hct.
- Implement bleeding precautions (avoid
giving injections if possible, caution client
to avoid activities that increase risk for
trauma, pad side rails if confused,
administer clotting factors, stop bleeding
if it occurs spontaneously, hold DVT
prophylaxis as ordered).
- Teach patient sign of bleeding. Instruct
patient to report orange or coffee color
urine, black stools, bruises, nose and gum
bleeding present. Instruct patient to use
soft toothbrush and electric razors,
increase fiber and take laxative to
prevent straining.

- Active bleeding
- Low coagulation
results
- Low CBC results
- Changes in LOC
- Hypotension
- Weakness
- Pallor
- Tachycardia
- Fatigue
- Shock
- Hypovolemia

Activity
intolerance
related to
pain and low
H&H

- Fatigue
- Refused participate
in physical
activities.
- Imposed activity
restriction
- Depression or lack
of motivation

- Assess patient energy and pain level.

- Assess the patients nutritional status
and sleep pattern.
- Instruct patient to increase calories
intake and select food that is high in
protein, vitamins and iron.
- Administer Iron as ordered.
- Monitor H&H level.
- Instruct patient to pace out activity to
conserve energy.
- Encourage active ROM exercises and
deep breathing using incentive
spirometer.

Potential
complicatio
ns

Strategies for prevention

Early recognition

Risk for
Ineffective
tissue
perfusion
related to low
H&H

- Assess and monitor vital signs, skin

color, sensation, movement, and capillary
refill on extremities
- Assess lower extremities for skin texture,
edema, ulcerations
- Encourage quiet and restful atmosphere,
frequent reposition and early ambulation
once tolerated, elevate affected
extremities
- Instruct to eat nutritious foods and foods
rich in iron.
- Elevated HOB as tolerated
- Monitor CBC count and report abnormal lab
- Anticipated for blood transfusion order
- Administer medication (iron) as ordered.
- Work with PT and OT for early ambulation

Risk for
infection
related open
fracture,
invasive
surgery,
surgical
wound and IV
assess.

- Fever
- Abnormal lab
values (increase
WBC)
- Redness, swelling,
or drainage to
surgical site

Strict hand hygiene

Assess body temperature regularly
Monitor lab data
Assess surgical incision (redness,
swelling, drainage, odor)
- Proper IV care. Use aseptic technique
during infusion.
- Educate patient about keeping surgical
incisions clean and dry. Assist MD with
dressing change. Anticipate wound care
order.
- Universal precautions
- Give sponge baths only if the patient has
a healing incision
- Administer antibiotic therapy as ordered
to maintain serum therapeutic level and
prevent.

Pallor
Pale lips
Thick finger nails
Discoloration of
skin, edema
- Capillary refill > 3
second
- Low H&H, RBC
- Low O2 sat, BP
- Increase RR, HR
- Pale conjunctiva
- Restlessness

Potential
complicatio
ns
Deficient
knowledge
related to
treatment
regiment

Strategies for prevention

- Assess ability to perform wound care,

verbalize appropriate activity and
describe appropriate diet
- Teach patient to preform appropriate
wound care
- Teach proper use and front wheel walker
to prevent fall.
- Teach about diet (high-calorie, highprotein, vitamins)
- Teach about importance of follow-up with
lab test
- Instruct the patient to seek medical
attention for temp >100.4F, foul smelling
wound drainage, redness or unusual pain
in any incision, or absence of BM

Early recognition

- Unable to verbalize
understanding
treatment
- Has many
questions about
treatment
- Unable to preform
wound care

Risk for DVT - Assess CMS (pain, pallor, parathesia,

and
paralysis, pulse)
neurovascula - Monitor platelet and coagulation test
r impairment results
- Early ambulation
- Administer IV fluids as ordered
- Instruct patient to report chest pain,
SOB.
- Instruct patient to perform ROM exercise
to prevent thrombosis formation.
- Elevated affected extremities with
pillows.
- Hold DVT prophylactic anticoagulants
until bleeding is clear.

- Intense pain
- Coolness of
extremity
- Numbness
- Pulselessness
- Tachycardia
- Increase calf size
circumference

Altered bowel
elimination
related to
anesthesia
and pain
medication
and limited
activities.

- Absent bowel
sounds
- Abdominal
distention
- Patient denies
passage of flatus
- Abdominal pain
No BM

- Assess bowel sounds, abdominal

distention, and presence of flatus or stool.
- Encourage fluids and fibers intake
- Encourage and assist with ambulation
and exercise.
Administer laxative and stools softener as
ordered. Hold laxative and stools softener
if loose stool present.

Potential
complicatio
ns

Strategies for prevention

Anxiety
related
hospitalizatio
n, surgery
and deficient
knowledge

- Assess patients perception and current

situation, available support, level of
understanding of current situation.
- Provide opportunity to express concern,
fears, feeling and expectations.
- Provide information about the current
situation and encourage patient to set a
realistic goals.
- Inform patient before doing a procedure.
- Be aware of client's feeling. Encourage
interaction with family and friends to
increase and mobilize support available.
Provide social therapy such as music,
television, and companionship as needed.

Risk for fall

related to
pain and
impaired
physical
mobility.

- Assess patient gait and proper use of

walker.
- Implement fall prevention. Have call light
and all necessary items within patient
reach. Raise bedrails up and place bed in
a lowest position.
- Instruct patient to call for help.
- Assist as needed.
- Perform and assist with range of motion
exercises.
- Administer pain medication and work
with PT and OT

Early recognition

- Anxiety
- Asking questions
- Rapid speech
-

- Unsteady gait
- Difficulty with
movement
- Reports of
pain/discomfort on
movement
- Limited ROM
- Decreased muscle
strength/control

#62. Dx: Left leg cellulitis, left heel ulcer, hx of methamphetamine

abuse. Homeless.

Potential
complications

Strategies for prevention

Early recognition

Acute pain
- Determine pain quality, severity, - Pt. reports pain
related surgical location, onset, duration, and
- Non-verbal signs of pain
wound
precipitating and alleviating
- Activity intolerance
factors.
- Monitor VS
- Administer pain medications
- Provide times for rest
- Respond immediately to c/o pain
- Evaluate patients response to
pain medications within 30
minutes.
- Notify primary nurse if
interventions are unsuccessful or
if current complain is a significant
change from the patients past
experience of pain.
- Encourage patient to use nonpharmaceutical pain management
techniques such as meditation,
imagination and distraction by TV
or music.

Potential
complications

Strategies for prevention

Early recognition

Risk for
infection
related invasive
surgery, open
wound and IV
assess.

- Strict hand hygiene

- Fever
- Assess body temperature
- Abnormal lab values
regularly
(increase WBC)
- Monitor lab data
- Redness, swelling, or
- Assess surgical incision (redness, drainage to surgical site
swelling, drainage, odor)
- Proper IV care. Use aseptic
technique during infusion and
wound care.
- Universal precautions
- Give sponge baths only if the
patient has a healing incision
- Administer antibiotic therapy on
time to maintain serum
therapeutic level and prevent.
- Instruct patient to keep surgical
incision clean and dry. Educate
patient to maintain aseptic
technique during dressing change
and change dressing as ordered
and report signs of infection.

Deficient
knowledge
related to
treatment
regiment

- Assess ability to perform wound

care, verbalize appropriate activity
and describe appropriate diet
- Teach patient to preform
appropriate wound care
- Teach about diet (high-calorie,
high-protein, vitamins)
- Teach about importance of followup with lab test
- Instruct the patient to seek
medical attention for temp
>100.4F, foul smelling wound
drainage, redness or unusual pain
in any incision, or absence of BM

- Unable to verbalize
understanding treatment
- Has many questions
about treatment
- Unable to preform wound
care

Potential
complications

Strategies for prevention

Early recognition

Risk for DVT

and
neurovascular
impairment

- Assess CMS (pain, pallor,

paresthesia, paralysis, pulse)
- Monitor platelet and coagulation
test results
- Use sequential compression
device
- Early ambulation
- Instruct patient to perform ROM
exercise to prevent thrombosis
formation.
- Elevated affected extremities
with pillows.

Intense pain
Coolness of extremity
Numbness
Pulselessness
Tachycardia
Increase calf size
circumference

Altered bowel
elimination
related to
anesthesia and
pain medication
and limited
activities.

- Assess bowel sounds, abdominal

distention, and presence of flatus
or stool.
- Encourage fluids and fibers
intake
- Encourage and assist with
ambulation and exercise.
- Administer laxative and stools
softener as ordered. Hold laxative
and stools softener if loose stool
present.

- Absent bowel sounds

- Abdominal distention
- Patient denies passage of
flatus
- Abdominal pain
- No BM

Potential
complications

Strategies for prevention

Ineffective
coping related
to pain, chronic
disease,
financial
situation
evidenced by
substance
abuse.

- Assess patients perception and

current situation, available
support, level of understanding of
current situation.
- Provide opportunity to express
concern, fears, feeling and
expectations.
- Provide information about the
current situation and encourage
patient to set a realistic goals.
- Be aware of client's feeling.
Encourage interaction with family
and friends to increase and
mobilize support available.
Provide social therapy such as
music, television, and
companionship as needed.
- Refer patient to a social work to
help obtaining shelter and
financial assistance and a detox
program, and vocational training
to obtain a job.

Early recognition
-

Substance abuse
Isolation
Uncooperative
Anger
Agitation

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 believe Im getting more comfortable with the use of the nursing
process to plan and evaluate nursing care each day. Im getting more
efficient in getting patients information from secondary sources and from
patient. I believe getting patient data is very important step as it gives me
the picture of patients condition so that I can prioritize nursing interventions
focus on problem patient presenting. For example, my priorities for #69 this

week were pain management, bleeding precaution, ineffective tissue

perfusion and risk for infection. I responded to my patients complain of pain
by giving pain medication immediately if it is in the time frame of order. I
also encouraged patient to use medication, imagination and distraction for
pain management. The pain medication was effect as patient verbalized pain
reduced from 6/10 to 3/10 after medicated. I also assessed wound dressing,
color of urine for bleeding. Clients dressing was wet with thin bloody
drainage. I discussed with RN about the need to notify MD. MD came to
assess and performed a dressing change. Iron was administered as ordered
and patient was instructed to increase high iron foods intake. I monitored BP,
dizziness, and energy level and H&H, RBC. Patient denied dizziness but
fatigue easily. Patient was alert and oriented, skin was pink and warm, O2 sat
was 97% and capillary refill was <3 second, both feet were slightly
edematous, CMS+, VS was stable. Patient needs to be continuing monitoring
for bleeding and tissue perfusion and sign of infection.
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, my nursing diagnosis and plan of care was individualized for my
patients. My #69 patient had hip and knees surgeries, which caused acute
pain and put him at risk for bleeding and infection and alter bowel
elimination. Therefore, my plan was to focus on pain, bleeding, VS, wound
and IV site, bowel status assessment. In addition, I provided nursing

interventions that focus of these priorities such as administering pain

medication, antibiotics, iron and laxatives. I also provided education about
treatments, nutrition, and signs of infection, frequent reposition and deep
breathing exercise.
My #69 patient had cellulitis and a heel ulcer. He was DC on my shift.
Thus, my focus was DC teaching about infection prevention, wound care,
home medications and side effects, and when to report to MD. In addition, I
assessed patient psychosocial support systems. Social worker also contacted
Ohana Project and H&E Reliable, transportation to accompany patient to
Ohana Project.

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).
Im getting more confident with my assessment skills and practicing to
ask the right questions. For example, for pain assessment, I asked patient to
describe the pain intensity, duration and characteristics of pain. I also
assessed CMS, distal to the affected area, for neurovascular impairment
present so that proper interventions can be implement early to prevent
complications. I believe Im still weak at assessing patient psychosocial
status. I will need to improve in when to ask and what question to ask so I
dont feel like I was invading patients privacy.
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?

The new skill I implemented this week was administering 200mg Iron
sucrose IV push. I learned from my clinical instructor that if I was not familiar
with any medication administration, I must carefully check the medication for
right dosage, administration guideline, and side effects or consult another
nurse before administering to prevent complications. I will keep this in mind.
I prepared all supplies I need for this procedure. However, I accidently
dropped a NS syringe but didnt have an extra one with me. I learned to
always have an extra item in the room. Also, I learned to be more carefully to
prevent dropping items. In addition, I also implemented discharge teaching
this week. It went quite well. I carefully educated patient and had him follow
a written instruction while I was educating him. I also had patient stated back
what he learned to verify patient understanding of instructions.
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?

Im continuing to improve on my time management skills. Having a
written brain with me at all the time keeps me stay on track. Also, I tried to
be present and keep in my mind of important task I need to do. I learned that
charting in the EMR right after each procedure save my time and keep me
organized. I feel that when Im more organized, I became more efficient and
thus giving me more time to converse with patient, assess patients
psychosocial aspect and provide comfort measurements.

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 was not involved in making referrals for my clients. My #69 client was
referring to RHOP for a short-term rehabilitation. In addition, he seemed
anxiety his condition and treatment sometimes. He may be benefited from a
psych consultation. However, RN already recommended to MD. He also was
referred to a social worker and case manager for discharge planning. He was
working with PT and OT to regain strength.
My #62 patient was already referred to a social worker to help him with
substance detoxification program and shelter. He was discharged to Ohana
Project. I probably could have referred him to River of Life for meal services.
8. List the specific interventions, in order of priority, for two of your clients
and explain how you determined which interventions took precedent.
#69 was at risk for bleeding and hemodynamics as his H&H has been
low. Thus, I must see him first. My priorities nursing care for #69 was focus
on pain, bleeding precaution, hemodynamic stablization and infection
prevention. Thus, I saw #69 first as he was post of day 4 and has been
having lot of pain and was low H&H. I checked his VS, assesses for need of
pain medication, assessed his IV, skin, urine and addressing for bleeding and
CMS and performed a head to toes assessment. I then administered pain
medication (4 hour since last administration) and PO meds with the RN. I
made sure all items are in his reach and positioned the bed at a lowest level
and instructed him to call for help as needed.

I went to #62 to take VS, assess for pain, assessed his IV and
addressing for bleeding and CMS. I performed a head to toe assessment and
administered PO medication and flush IV line as ordered. I told him I would
be back with hygiene items so he can get ready to go to Ohana Project in the
afternoon.
I went back to #69 to perform pain reassessment to see if the
medication was effective and provide comfort and hygiene measurements. I
also performed psychosocial assessment and patient education about
nutrition, deep breathing exercise, and bleeding and infection prevention.
I then assisted #62 with hygiene, DC his IV and provided discharge
teaching with RN for #62.