Student Name ___Shy Wegiel____________________

Date ___03/14/14- Week 2____________

N360 Weekly Self Evaluation 1. Considering your patients current status, list potential complications early recognition. Potential Complication Prevention Strategies Risk for hemorrhagic Maintain B/P within parameters. Stroke Administer antihypertensive medications. Monitor B/P. Assess for symptoms of HTN. Focus neurological assessment. Risk for hypertensive Maintain B/P within parameters. crisis Administer antihypertensive medications. Monitor B/P. Impaired physical PT participation, encouraged ROM mobility exercises. Assess patients muscle strength of each extremity. Assess for any weakness. Risk for DVT PT participation, encouraged ROM exercises, SCD, up to chair TID. Provide bed pan, empty urinal, encourage participation in care such as bed bath.

and strategies for prevention and Early recognition Assess for symptoms of hemorrhagic stroke (severe HA, N/V, neck stiffness, dizziness, seizures, decrease LOC). Assess for symptoms of HTN (HA, blurred vision, CP, nose bleeds, dizziness or weakness, SOB). Inability to move purposefully within physical environment (transfers, ambulation). Assess for decreased muscle endurance, strength, control, or mass. Assess for swelling, pain or tenderness, warmth, erythema on lower extremities. Incontinence, inability to independently ambulate, inability to tend to own hygiene (bed bath, perineal care). Decreased appetite.

Self-care deficit

Altered nutrition

Risk for skin breakdown

Risk for falls

Risk for ineffective cerebral tissue perfusion

Monitor I & O, BM, appetite (inadequate50% of meals). Assess for N/V, active bowel sounds, and flatus. Braden (skin breakdown) assessment. Turn patient every 2 hours. Up to chair TID. PT participation. Keep objects within reach. Place bed in lowest position. Leave call light within reach and encourage its use. Assess patients muscle strength of each extremity. Assess for any weakness, dizziness, or lightheadedness. Review morning orthostatic B/P results. Fall risk assessment. Focused neurological assessment. Assess pupils, decreased LOC.

Red skin that forms a blister then furthering resulting into an open sore. Assess for decreased blood pressure, light-headedness, incontinence. Avoid falls by assessing muscles strength, fall risk assessment, put rails up.

Decreased LOC, HA, blurred vision, etc.

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 am getting more comfortable with using the nursing process to plan and evaluate nursing care. My patient was experiencing a headache. HA is a symptom of HTN and hemorrhagic stroke. My patient was admitted for a hemorrhagic stroke. I assessed his B/P and whether or not he was experiencing any symptoms of hypertension (N/V, palpitations, blurred vision, CP, nose bleeds, dizziness or weakness, SOB). I also reviewed his history and noticed that he has been having intermittent headaches since his admission. (I discussed the use of better, worse, or the same later in my reflection.) After assessing his pain level, quality, location, and frequency, we administered Tylenol to him. An hour after, I evaluated the effectiveness of the intervention by reassessing his pain. It is important to evaluate the effectiveness of the interventions you implement.

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). My nursing diagnosis and plan of care were individualized for my patient. I reviewed his history and noticed that he was noncompliant with receiving any prior treatment for his hypertension. He also did not have a primary care physician. After morning assessments were complete, I helped him review a list of primary care physicians provided by the unit secretary. I completed a focused neurological assessment since my patient is a post stroke patient. I assessed his B/P since he was taking antihypertensive medications. I assessed him ability to independently reposition himself and reviewed his previous assessments related to mobility and fall risk. I also assessed his strength and coordination in upper and lower extremities. By reviewing his history and comparing my current assessments, I would be able to notice any changes. 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 coming along. I performed a focused neurological assessment because my patient had a stroke. With this assessment, I assessed his ability to swallow, PERRLA, equal strength and movement of his extremities, LOC, sensation, dizziness, tingling, HA, etc. It is important to be thorough because my patient may have weakness resulting for his stroke. He is also at risk for a recurrent stroke. I can improve by being more fluid in my neurological assessment. I had to think of what was included in a neurological assessment which slowed me down a little bit. Now that I have completed a focused neurological assessment and reviewed important areas to assess, I am better prepared to implement quicker, efficient neurological assessments in the upcoming weeks. 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? This week we discussed the use of worse, same, or better to evaluate a baseline for our patients. For example: my patient state was experiencing intermittent headaches throughout his hospital stay. To obtain more information related to his headache, we assessed whether or not he had a headache before being admitted into the hospital. He said, Ive a headache on and off for a few months. We asked whether his headache has gotten worse, better, or is it still the same since admission. He said that his headache pain has gotten better since admission. It would be concerning if his headache had gotten worse since admission. This thorough assessment was helpful because it created a baseline picture of my patients headache prior to admission. I plan to continue use this assessment for my patients. 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. We had one patient this week so it wasnt too bad. I was extremely busy because my patient needed a lot of assistance. He was incontinent and needed assistance. He was also having difficulty participating in hygiene care. I needed to complete frequent B/P assessments to determine the effectiveness of his antihypertensive medications. I am learning more about how to organize my time and create a plan. I am also becoming more aware of where all the supplies are in the clinical setting. I spend less time looking for things and more time managing my time efficiently. 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 am becoming more and more comfortable with making referrals for my client. While at clinical this week, my patient was prescribed 3 antihypertensive medications to treat his hypertension. I noticed that his systolic blood pressure dropped 20mmhg when I administered all 3 medications that day before. Today his B/P started off at 134/92. I was concerned about administering all of the medications because he didnt have any parameters in the computer system. This is difficult because I dont know what his blood pressure goal was. I informed the nurse of my concern and she contacted the physician to obtain parameters. The new nursing communication order parameters stated (keep B/P between 100-140s systolic). I also informed her of his previous drop in B/P from the medication and my concern about administering 3 of the antihypertensive medications. She agreed that we would administer 2 of the medications and monitor his B/P to determine if these medications were sufficient. The nursing role in this process could be strengthened by being more straightforward and clear about my recommendations.

I monitored his B/P which decreased to 118/84, but she decided to administer his 3 antihypertensive medication. This was against my recommendation. These medications all peak in about 6 hours or so. I was concerned about the potential hypotensive side effects. I explained these concerns to the nurse but she wanted to administer the medications anyways and so I respected her decision. 8. List the specific interventions, in order of priority, for two of your clients and explain how you determined which interventions took precedent. Intervention 1. Assess LOC 2. Vital signs Explain Determine if he was oriented person, time, place, and situation. To assess for a drop or raise in any vital sign. Changes could be caused by a number of different reasons (infection, hypotension, hypertension, hypovolemia, etc.) Pt has a history of untreated HTN and admitted for a hemorrhagic stroke. He is also on newly prescribed antihypertensive medications. Maintaining a B/P within prescribed parameters will ensure adequate perfusion and prevent HTN which increases the pts risk for a recurrent hemorrhagic stroke Pt recently experienced a hemorrhagic stroke. Completing a focused neurological assessment will determine any residual effects from the stroke. He is also at risk for a recurrent stroke. The physical assessment could indicate changes in the patients status whether its improved, the same, or worse. This also paints a picture for myself of the patient. From reading about previous assessment and comparing them with my own assessments, I can identify any discrepancies. Pain (HA) could affect pts ability to participate in PT. Treating pain also results patient comfort. Severe HA is a symptoms of hemorrhagic stroke. Ensuring SCD is on patients leg while he is in bed with decrease his risk for DVTs. Keep objects within reach. Place bed in lowest position. Leave call light within reach and encourage its use. Post stroke could result Review morning orthostatic B/P results. Pt is on antihypertensive medications which could result in hypotension. Ensuring adequate nutrition and UOP. Pt is also on stool softeners. Assessing him BM is important to ensure we dont administered too much laxatives resulting in diarrhea. Infiltration and infection could have potential complications. Education on medications will increase adherence and awareness. Understanding more about his medications will be beneficial for him once he is discharged. Pt is at risk for impaired mobility. PT will also get him out of bed and decrease his risk for skin breakdown.

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3. Administer antihypertensive medications 4. Focused neurological assessment 5. Completed physical assessment

6. Assess for pain

7. SCD 8. Decrease risk for falls

9. Monitored I & Os

10. Assess IV site 11. Educate on medication regimen 12. Encourage participation in PT