Student Name: Grace Kim

Date: 10/17/14

N360 Weekly Self Evaluation

1. Considering your patients current status, list potential complications and strategies for prevention and
early recognition.
Potential Complications
Infection at surgerical site

Risk for falls due to pain with

movement

Early Recognition
Fever, WBC, loss of appetite,
swelling/tenderness/redness at
incision site, chills, high blood
glucose
Unsteady gait, orthostatic
hypotension, dizziness,
lightheadedness

Prevention
Hand washing prior to examining
incision site, gently wash area
with soap and water
Check BP when laying down,
sitting, and standing up. Provide
a walker. Assist with ambulation.

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).
This was the first week of clinicals, so I really cant say whether I am getting more comfortable with
using the nursing process. However, I can definitely say that I need to brush up on my nursing
planning and evaluation. After getting feedback from my instructor this week, I plan to create a better
nursing care plan to assist my patients for next week.
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).
I feel that my nursing diagnosis and plan of care was pretty well individualized for my patient. For
example, I planned to get my patient ready for discharge by getting my patient to ambulate up and
down the hall, get her weaned off of her nasal cannula to room air, and get her to an acceptable pain
level as well. I also planned to educate her on S&S of infection and how to care for her incision site at
home.
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).
On the second day of clinical, I did much better with my head to toe assessment. I was very thorough,
and made sure to do a focused assessment on my patients PIV sites and incision sites. I was really
embarrassed when I forgot to take off my patients socks and check the capillary refill time, so that is
something I definitely remember to do now.
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 was able to d/c a PIV, which was not really a new skill per se, but it was nice to practice it. I think I
did well with that. I almost had an opportunity to give a flu shot, but I wasnt able to do it due to some
complications with my patient.
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?
I think I am doing okay with my time management. Since I only have one patient, I am able to really
focus on her. I feel that once I start working as an RN, administering meds will take up a lot of my
time. I was able to shadow a nurse on both clinical days, and I received great tips on how to manage
my time when I am on my own.

7. Was I involved in making referrals for my client in any way? How could the nursing role in this
process have been strengthened?
Im not sure if I was able to make referrals for my patient, but I was able to advocate for her. First, I
noticed that my patient had only eaten 50% of her breakfast, so I asked about her appetite. She
informed me that she didnt eat the rest of her breakfast because she didnt have any salt. So I called
dietary and requested salt packets for her after making sure that she was allowed to have them. Also,
when I asked her about her pain level, she stated that it was 8/10. Therefore, I asked her if she
wanted her PRN pain medication, and she said she did, so I told the nurse.
8. List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.
Patient 1:
1. Assess incision sites for S&S of infection. This was my priority because her surgery was done
in an emergent situation, and therefore there was a higher risk of infection.
2. Assess pain level and characteristics. This was my second priority because my patient was
post-op day 4&5. Pain management is always at the top of my priority list.
3. Anticipate need for pain relief. This was my third priority because my patient had PT and OT
scheduled, and if she were in pain, she would not be able to ambulate well.
4. Assess environment for factors known to increase fall risk. This was also a priority because my
patient was a moderate risk for falls.
etc...

Patient 2: no second patient

1.
2.
3.
4.
etc