wk1 Selfeval Tching

Student Name __________Tiffany Ching___________ Date ________3/5/17________
N360 Weekly Self Evaluation #1
1. Considering your patients current status, list potential complications and strategies for prevention and early
recognition.
Considering that respiratory insufficiency is my patients current status, some complications are pulmonary embolism,
pulmonary fibrosis, cor pulmonale, hypotension, reduced cardiac output, arrhythmias, pneumonia. Strategies for
prevention may include ambulating at least 3 times a day, proper nutrition and hydration, incentive spirometer 10
times every hour while awake, and deep breathing exercises. An early sign of her status could be shortness of breath
upon exertion and her LFTs.
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).
After our first week of clinical, I realize that in time I can become more comfortable with using the nursing process to
plan and evaluate my care for my patients. I feel that I understand the nursing process, however I can improve on
planning care for my patients better.
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).
During our first week of clinical, I feel that I can improve on keeping a focused plan for my patient and direct majority
of my care towards that goal. For example, I should be more focused on improving my patients breathing pattern
rather than her pain or comfort level first.
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 assessment skills are developing as I assess more patients with my nurse. I can improve on being more thorough
for my head to toe assessments by remembering to assess for pupillary reaction, and going down the list of body
systems. I feel that listening to heart sounds, murmurs, and rubs are still difficult for me because I have not had much
practice in hearing what it sounds like in the clinical setting. I can improve this skill by listening to more patients as
well as educational videos.
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?
Some new skills I implemented this week was flushing a PICC line with my nurse and assisting a wound care nurse
with changing a wound vac dressing. I felt that I did well with flushing the PICC line and in the future, I can improve by
being more confident in performing a skill in front of the patients family and nurse. During the wound vac dressing, I
asked the nurse to explain each step because I have never seen it done before and that way I dont waste her time if I
make a mistake.
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?
My time management is progressing gradually with the 1 patient I had during the first week. Time management is
something I can work on because at times, I find myself stuck in a patients room longer than I need to be. I can better
manage my time in the clinical area by doing what needs to be done in the patients room at once so that they dont
have to call for me shortly after I leave the room.
7. Was I involved in making referrals for my client in any way? How could the nursing role in this process have been
strengthened?
At this time, I was not involved to make any referrals for my client in any way because I was to shadow my nurse as
our first week of clinical. The nursing role in this process could have been strengthened by advocating for my patient
for the therapy she needed while in the hospital and when she gets discharged. I could have been more proactive in
finding out more information of whos going to take care of her after and the kind of help she needs (ex: meals on
wheels, physical therapy, home health aide/nurse).
8. List the specific interventions, in order of priority, for two of your clients and explain how you determined which
interventions took precedent.
a. Assess respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal
breathing patterns. (Priority because it will determine patients respiratory status & determine plan of care).
b. Monitor patients behavior and mental status for onset of restlessness, agitation, confusion, and (in late stages)
extreme lethargy. (Will determine the severity of patients respiratory status.)
c. Using pain scale, assess location, character, duration, intensity as well as alleviating, aggravating and precipitating
factors. (Pain is second priority because it will help make the patient comfortable and decrease respiratory effort.

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Student Name ____Tiffany Ching_ Date 3/5/17____

N360 Weekly Self Evaluation #1

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