Weekly Self Evaluation

Week 1 & 2
Manaia Genovia

SLO: Practice as a member of a multi-disciplinary health care team

This week in clinical, I actually felt like a member of health care team for my patient
instead of just an observer or helper. I completed my head-toe physical assessment with the
primary nurse who did a focus assessment instead of a thorough assessment. I read in the notes
that my patient had a heart murmur but when I listened to his heart sounds I wasnt sure on
what I should be hearing. I should have asked the primary nurse while we were doing the
assessment together. Later, I asked my clinical instructor to help me listen to his heart murmur
and now I know what to listen for in the future. I did not find any abnormal findings therefore I
reported to my CI and primary nurse that everything was within normal limits. When my
patient had a fever of 100.5F, I immediately told the primary nurse, who then instructed me
administer p.o. Tylenol and she would call the doctor to find out what they would like us to do.
My patient has a PICC and is on antibiotics so any sign of infection (fever, increased pain,
elevated labs) should be reported as soon as possible.

SLO: Demonstrate therapeutic communication skills in interactions and relationships

with families, individuals, and other members of the health care team with attention to the
identification and correction of non-therapeutic communication techniques.

This week in clinical, I had a thirteen-year-old male patient who has been in the
hospital for the past 3 weeks. Immediately, I asked him what his daily routine was so I could plan
around his day. I told him that my I would come around every hour to check him and at 0800 /
1200 I would take his VS and complete a head-toe physical assessment. He has a lot of people
coming in and out of the room, so I thought it would be important to let him know my objectives
for the day and want I needed to do with him. He was slightly irritable when I did my 1200
assessment and was saying no when I asked him if I could check his eyes with a penlight. He
asked me if he could do it to my eyes. I was hesitant at first, but I realized if he understood the
rationale he wouldnt be as resistant, so I allowed him to check my pupil reflex, which he got
very excited about it. I then explained the rationale behind checking his pulse, listening to his
lung/heart sounds, and capillary refill and he seemed very engaged. I learned that adolescents
like to know what to expect, so I kept that in mind during my time with my patient.