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CLINICAL MANAGEMENT EXPERIENCE

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; 10-1

MANAGER 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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