NUR 210 – NURSING CARE IV-A
SELF-EVALUATION OF CLINICAL MANAGEMENT EXPERIENCE
Self-evaluations are submitted on the Wednesday following the clinical experience.
Please include the following information in your evaluation:
Name: Rashidat Jamiu
Team members’ names: Jasmin Amir; Shanon ;Siobhan
Date: 11/25/20
Clinical Week: 4
Using APA style, provide a brief analysis of one nursing practice that you observed during your week as manager. Find at least two references to support that the practice observed is evidence based practice. See the Library website for APA style: https://www.dtcc.edu/sites/default/files/apacolor.pdf Required length is 1-2 pages. The paper needs to be a separate attachment from your self-evaluation.
A. Identify the priority nursing diagnosis that should be addressed for each of your team members’ patients. Your written work should be independent of your team members’. Please include the patient’s initials with the corresponding diagnosis.
B. Answer the following questions. Please include the questions or stem in your responses.
1. My clinical performance as a manager was strongest in the following areas:
2. I provided the following nursing care:
3. If I could repeat this clinical week, I would do the following things differently:
4. I feel that I could improve in the following areas:
5. My plan for improvement in these areas includes the following actions:
6. The most important thing I learned this week was:
Comments/concerns not addressed above:
09-1; 10-1MANAGER WORKSHEET
Name/Rm #Jasmin Amir
Focused Assessment
Plan of Care/Items for Follow-up
Patient initial: G.Z
VS: 37.5 98, 17 148/92
IV: Capped double Lumen PICC, L forearm Peripheral IV line
Accucheck: No
Diet: NPO, osmolite 1.5@65ml/hr via pegtube
Foley: None
NG: None
Labs/Tests: elevated WBC
Restraints:None Renewal: N/A
Neuro: Awake and Alert x3, quadriplegic
CV: Regular heart rhythm
Resp: Vent dependent, coarse BS
GI: Positive bowel sound, pegtube, on bowel regimen
GU: Urinary retention, CAT scan q 6hours, bladder scan, straight cath > 500ml
Skin: Dry, warm, with no rashes. Pitting edema to B/L lower extremities
Pain:7 out of 10 pain reported; oxycodone given
Patient Febrile @ 38.0, rechecked and down to 37.5
Dx: elevated body temperature related to underlying condition
Goal: Patient temperature will stabilize within normal limits
Intervention: assess the patient VS Q 4 hours. Apply cooling blanket on patient and ice packs underarm pit. Administer prescribed antipyretics
· Pegtube dislodge 11/24/20, VIR replaced it
Name/Rm #
Focused Assessment
Plan of Care/Items for Follow-up
Patient initial: F.C
VS: 36.8, 71, 15, 94% 127/62
IV: 22gauge anterior forearm peripheral line
Accucheck: Q 6 hours
Diet: Nepro with CHO 45ml/hour with q2hours flush of 25ml via pegtube.
Foley: Texas catheter draining clear yellow urine
NG: None
Labs/Tests: elevated K, elevated cl, decreased C02, elevated BUN, elevated creatinine, and decreased Albumin
Restraints: None Renewal: None
Neuro: Awake and alert
CV:
Resp:
GI:
GU:
Skin:
Pain:
Name/Rm #
Focused Assessment
Plan of Care/Items for Follow-up
VS:
IV:
Accucheck:
Diet:
Foley:
NG:
Labs/Tests
Restraints: Renewal:
Neuro:
CV:
Resp:
GI:
GU:
Skin:
Pain:
Name/Rm #
Focused Assessment
Plan of Care/Items for Follow-up
VS:
IV:
Accucheck:
Diet:
Foley:
NG:
Labs/Tests
Restraints: Renewal:
Neuro:
CV:
Resp:
GI:
GU:
Skin:
Pain:
Name/Rm #
Focused Assessment
Plan of Care/Items for Follow-up
VS:
IV:
Accucheck:
Diet:
Foley:
NG:
Labs/Tests
Restraints: Renewal:
Neuro:
CV:
Resp:
GI:
GU:
Skin:
Pain:
Name/Rm #
Focused Assessment
Plan of Care/Items for Follow-up
VS:
IV:
Accucheck:
Diet:
Foley:
NG:
Labs/Tests
Restraints: Renewal:
Neuro:
CV:
Resp:
GI:
GU:
Skin:
Pain:
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