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Student Name: Charleen Kahapea

Date: October 30, 2015

Date of care: October 27, 2015

N360 Weekly Self Evaluation

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

strategies for prevention


early ambulation
encourage DB&C
encourage IS
turn patient q2h
monitoring VS (fever)
monitoring for respiratory changes


assess surgical site for drainage

having a drain (HV/JP)
monitor amount of drainage
monitoring labs (H/H & platelets)
monitoring BP and HR

wound infection

- keeping surgical site clean and dry

- aseptic technique when doing dressing
- administering antibiotics
- monitoring the surgical site for changes
- monitoring VS
- assessing surgical site every shift with
dressing changes
- monitoring for changes in wound
- keeping surgical site clean and dry
- reposition carefully to prevent shearing
- drinking a lot of fluids
- eating at least half his meals
- ambulating
- taking stool softeners as needed
- monitoring last BM
- assessing stomach for distention &
- checking BS
- ted hose
- early ambulation
- anticoagulants

wound dehiscence



compartment syndrome

CMS checks
check for numbness and tingling
monitor dressing for tightness
monitor for change in the surgical
- assess for swelling, elevating the
affected extremity

early recognition
- fever, muscle aches, fatigue, chest
pain, sore throat, coughing, feeling like
you have a cold
- possible N/V, diarrhea
- SOB, rapid breathing, possible
- crackles on lung auscultation
- x ray shows fluid in the lungs
- lab changes
- dressing drainage (note amount &
marking the site)
- bleeding gets onto clothes or bed
- monitor labs (decrease H/H and
- VS changes such as tachycardia &
hypotension d/t hypovolemia)
- increase swelling and pain
- VS changes such as fever, tachycardia
- elevated WBC & ESR
- erythema and pain in the wound edges
- drainage and odor smell
- change in sensation to wound

wound looks infected

wound is starting to open
wound looks like it is not healing
wound is draining

- no bowel movement in awhile (2 days

+ or depending on their usual BM)
- decrease in PO intake
- taking narcotics
- not/ minimal ambulating
- dehydrated
- redness, swelling, warmth &
tenderness to extremity
- fever
- + Homans sign: calf pain upon
dorsiflexion of foot
- monitoring CMS
- assessing pain, pulses, able to move &
feel extremity
- assess skin temperature and color
- neurovascular checks (5Ps):
Pallor (color)
Parasthesia (feel)
Paralysis (move)

impaired mobility d/t pain

Fall risk


dislocation of the hip

- administering pain meds to keep pain

under control
- administering pain meds before therapy
- encourage exercise
- remind pt to call before getting out of
- using bed alarms
- checking on pt every hr
- making sure pt has everything in reach
- making sure pt has call light with in
- making sure bed is in lowest/locked
- apply ice packs
- reposition
- administer pain meds timely
- pain assessment
- total hip precautions: no bending more
than 90 degrees, no turning toes inward,
to crossing legs at the thighs
- using an elevated toilet seat
- notting sitting on low chairs
- caution when getting in and out of the
- no driving until cleared by MD
- no jumping, running, twisting until
cleared by MD
- keeping a pillow between your thighs
when turning onto the side
- sitting to standing: scoot to the edge &
then extend surgical leg when standing
- standing to sitting: make sure your
knees touch the back of the seat, extend
surgical site forward, reach back with
one hand to brace yourself.
- use of assistive device (FWW, crutches,
cane) and wt bearing status till cleared
by MD/PT

- patient doesn't want to move

- patient is guarding area of pain
- unrelieved pain

patient trying to get OOB by self

unsteady gait
recent surgical procedure
patient moving down toward the foot of
the bed to get out
patient not listening when reminded to
call before getting OOB
bed alarm going off when patient is
trying to get OOB
guarding the surgical site
doesnt want to move extremity/area
moaning/ grunting
pt complains of pain
severe pain in the hip with movement
pain that spreads to the legs, knees,
and back
leg on the affected side appears
shorter than the other leg
hip joint appears deformed
pain or numbness along the back of
thighs if injury presses on the sciatic
unable to walk

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 feel that I am getting more comfortable trying to go in with a plan and area of focus for my patient.
Thinking in my head what needs to be done so that my patient can get better and be discharged. I feel
good at the end of the shift, with your help and guidance, but I want to be able to think more on my own to
do a thorough plan and evaluation to benefit my patient.
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, I tried to focus on areas of concern for my pt. For the hip replacement patient, I know the biggest
complications are bleeding and infection, so I focus on that and then I am able to focus on other
complications to monitor for. I changed my nursing dx after assessment. My patient was not fatigue d/t
anemia and was getting up to the bathroom with a steady gait and adequate energy for ADLs. Ineffective
tissue perfusion was important, but there was no s/sx of infection so I focused on actual problems such as
her fatigue and nausea she had during my shift.
-Yes, I feel I have difficulty recalling all the plan of care in my head, such as knowing my patient has a
fever. As, being an aide & being unable to give meds I know to recheck immediately, if I need to use
another source to check (such as not using an oral thermometer if they just ate/drank), if there is not
another source besides an oral them, I will tell them not to eat/drink for 15 mins and then I will come back

to recheck their temp, if using a temporal or tympanic, I know to use proper technique (such as pulling the
top of the ear up, making sure there is no wax blocking my reading), I know to instruct patients to use the
IS, DB&C, and drink plenty of fluids.
- Hopefully by the end of this rotation I will have better recall memory.

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).
- I feel my assessment skills are improving weekly. I definitely would like to improve so that when I get
out in the real world it wont be so foreign to me. I feel that I can practice skills to become more confident.
But what I really want to gain out of this last clinical experience with a strong critical thinking instructor is
to have that critical thinking in my brain. I want to be the nurse with brains and common sense. I hope
that by the end I will continue to improve on my assessment skills so I don't have to keep going back and
forth in my patients room because I forgot to assess something such as if they are having chills when
they have a fever.
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 first day I had help to teach my patients family how to do a dressing change, realizing I need to
explain each step as we were taught and what to look for such as s/sx of infection or wound
- The second day, I asked my classmates how to calculate the drips in so many seconds. We got it
mixed up, but I think I got it down. I learned to use the dial flow. I learned that its like a manual pump,
but even though you need to count the drip rate to make sure its going at the ordered rate. I learned
that when you have the dial flow and using a secondary to hang the antibiotic, the antibiotic will stop
and switch over to the primary bag automatically so the line does not go dry, but you must go back in to
adjust to the ordered rate for the primary bag.
- Practice and practice and learning from my mistakes will help me to improve.
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 my time management is going good, well I thought it was going good the first day. Things were
good then it got busy towards the afternoon. I was told my patient would probably go rehab around 3p
or 4p. But instead the nurse aide told me at 1p to change her clothes because she was going to be
picked up for rehab at 2p. She had a fever in the afternoon vitals, so I had to take care of that and get
her ready to be picked up. At least I learned to do discharge teaching throughout the day incase they
are discharged soon. I feel I became aide focused a little, I told you of the temp, but I did not remember
to assess if she was symptomatic (chills & warmth) or asymptomatic. Also I felt a little clueless when
you asked me my plan, which I should automatically know is to recheck the temp.
- The first and second day I was able to give care for my patients and assist my classmates with
changing their patients and changing their linens. I love being able to assist then because I know nurse
aide skills can also cause some anxiety, especially moving patients, but its something I am comfortable
- I also know now it is ok to just drop my DAR with you when I am done, I was waiting around to give it to
you, but I knew you were busy, so I didnt want to interrupt you.
7. Was I involved in making referrals for my client in any way?
process have been strengthened?

How could the nursing role in this

- I dont think I made any referrals this week. I did notice my second day that my patient wanted to go
home, but they were still trying to figure out what was wrong with her. I kept asking her throughout the
shift if she had any questions. I also tried to explaining to her that it would be better she stays in the
hospital a little longer for them to run another X-ray. That also she is already here and they can monitor
her if she doesn't feel good, but if she goes home and doesnt feel good she will have to come back to the

ER and wait around in the ER for them to see her. She agreed with me that it would be best to just stay
so they can figure out what is wrong with her.
8. List the specific interventions, in order of priority, for two of your clients and explain how you
determined which interventions took precedent.
1. Assessed patients vital signs for abnormalities such as fever, tachycardia, and hypotension.
-> Abnormalities from the normal finding could indicate infection, DVT, or bleeding.
2. Assessed surgical site: CMS check and neurovascular check (5 Ps). Wound site assessment (when
doing dressing change) such as wound approximation and dehiscence. Checking for signs of infections:
drainage, bleeding, pain, warmth and pain.
-> Abnormalities from the normal findings could indicate infection and /or bleeding.
3. Assessed for positive Homans sign. Edema, redness, or warmth.
-> This positive finding could indicate DVT in the extremity.
4. Pain assessment. Last pain medication time and med effectiveness.
-> Having good pain management is beneficial for effective recovery. Allowing patient to be able
to move in and out of bed and do therapy. Since patient also had hip surgery, so pain would be
5. Assessing assistance needed for ADLs and mobility.
-> Since my patient had hip surgery, getting in and out of bed with a assistive device would be
expected to maintain weight bearing status orders (such as WBAT while in first stage of
6. Educated my patient on total hip precautions such as no bending more than 90 degrees (and gave
example of dropping something on the floor and reaching down to pick it up), to turning toes inward and
no crossing legs.
-> This is important so she does not accidentally dislocate her hip.
7. Educated on what symptoms she may feel if she accidentally dislocates her hip such as excruciating
pain and being unable to walk or move the extremity, and the joint looks deformed or different compared
to her other leg. So, to notify her MD immediately.
-> This is important because if she dislocates her hip she will need to be readmitted and
evaluated to see if she needs her hip to be adjusted or if she needs to go back into surgery to fix.
8. Assessed her nausea, assisted for repositioning for comfort, pt had IVP prn for anti nausea, so I asked
the RN she was nauseated.
-> This was important because my patient was not comfortable, and it was important to get the
nausea under control so she wouldnt end up throwing up.
9. Made sure she had her ted hose and venodynes on while in bed. Also doing ankle pumps while laying
in bed.
-> This was important because she was only getting out of bed to the bathroom a couple times
(2-3x) during my shift. And to prevent DVT.
10. Encouraged use of IS and DB&C to increase oxygenation to her lungs.
-> This was important to prevent complications of pneumonia and fever after surgery and
from decreased mobility. This also would help to bring her temperature down.
11. Assisted with ADLs (bath).
-> Some assistance is expected after surgery and takes time for a patient to regain full function
for self independence in ADLs. Plus my patient was nauseated and not feeling well, but was ok
with me helping her to wipe down after she had some anti-nausea meds administered.
12. Educated the family on how to do a dressing change. Such as using one pad for each swipe from top
to bottom of the incision site. Starting from the middle and then swiping on the outside of the staples.
Making sure not to touch the inside of the dressing.
-> Using aseptic technique prevents infections and keeps the surgical incision site clean.