Nursing Self Evaluation

Student: 

EXAMPLE,

 Date : 

TRIMESTER III 

Clinical Area: 

ASSESSMENT: 

SCORE 

COMMENTS 

* 1. Collects data through appropriate physical assessment techniques: 

a. Physical assessment demonstrates knowledge of anatomy & physiology. 

b. Physical assessment data collection is adapted based on the patient’s developmental level. 

5 

6/29 Conducted focused head to toe assessment on patient Q4H on two patients based on their LOC. 

7/2 Restraints were applied to patient for safety reasons. Assessed and monitored the patient closely Q15 minutes to ensure restraints were not too tight and assessed the skin integrity underneath the restraint 

7/6 Assessed intubated p/t’s LOC and vitals Q1h, ensured patent airway and mechanical ventilation. Measured I/O Q1H, and documented sores on skin and pressure injuries  

7/13 Patient had PVD and DKA with venous stasis ulcer on right anterior tibia and 3+ edema on all four extremities. He had bronze pigmentation on both feet anteriorly. I assessed his blood glucose hourly via ART line and conducted skin checks Q1H 

7/15 P/t recovering from MI. Made sure to monitor BP/P and pain levels Q30 min. Auscultated heart sounds, and monitored p/t for signs of heart failure and additional acute symptoms.  

7/20 P/t had COPD and was desaturating with O2 levels at 84. We provided her with Bipap to increase her levels to 100.  

7/27 Used PAINAD scale for p/t with dementia and Guillain-Barre. She ranked a 7, which means she was in pain. Provided acetaminophen to help. Reassessed pain within Q45 min which decreased to a 4. 

7/29 P/t recovering from myocardial infarction. Monitored continuous telemetry for dysthymias patterns. Auscultated HR and assessed pulses Q1H 

7/31 Patient recovering post spinal fusion. Monitored for s/s of DVT and documented JP drain fluid prior to removal. 

8/2 Patient had end-stage renal failure and provided hourly glucose checks 

2. Collects data (subjective and objective) from available resources: 

a. All references/resources are appropriate, practice-specific professional journals and texts. 

          b. Interviewing techniques are used to collect data from the patient. 

          c. All pertinent diagnostic and screening values are analyzed and noted appropriately to the level of the result. 

          d. Aware of all current medical and nursing orders for the patient. 

          e. Continually assesses the patient and environment. 

4.5 

6/29 Utilized Davis’ Drug guide to research top 15 medications commonly used on the ICU floor. Learned common dosages, routes, mechanisms, nursing implications and common side effects. 

7/2 Took electrolyte panel and found p/t’s K+ at 2.9. Helped preceptor notify HCP and recommended an order of KCI  

7/2 Monitored serum electrolytes, CBC blood panel, and Q1h hour blood glucose levels (p/t did not decrease BG under 300 throughout entire shift) 

7/13 I monitored my preceptor conduct a blood transfusion with my patient who had Stage 4 Chronic Renal Disease. She used 0.9% Sodium Chloride with PRBCs and helped her monitor patient for first 15 minutes for any reaction. This was the first time I had seen a blood transfusion and was in line with evidence-based research along with what we learned in our Lewis textbook. 

7/15 Aware of all current medical and nursing orders for the patient-helped ambulate Q2H, took blood glucose levels Q1H, and helped with medication administration throughout the shift. 

7/20 Used interpreter as an interview technique. P/t only spoke Vietnamese so we provided her with an interpreter to help explain procedures and answer questions/ 

7/27 Used motivational interviewing techniques to work with patient with dementia. She was hesitant to answer at first but after I spent some time with her, she began to open up and answer my assessment questions. 

7/29 Assessed patient’s ability to ambulate post MI. Monitored vitals and promoted rest when necessary 

7/31 Interviewed patient during assessment and inquired about her current pain level. Expressed it was 8/10 so administered hydromorphone under supervision of preceptor 

8/2 Based on patients blood glucose levels, I adjusted the patient’s insulin dose based on a sliding scale 

* 3. Documents assessment data in a clear and organized manner: 

a. Adapts documentation to setting/patient. 

          b. Takes the initiative to document all findings, procedures and assessments 

5 

7/2 Documented skin integrity when p/t was in restraints Q15. Noted time/date and checked skin integrity and circulation distal to the restraints.  

7/6 P/t was morbidly obese and had sores under her skin folds along with stage 1 pressure injury from bed rest/intubation. Assessed skin and documented all findings Q2H, found no s/s of infection 

7/13 P/t needed Q1h assessments along with a multitude of medications. I helped assess and documented my findings on the shift report document in an organized matter by body system.  

7/15 Helped preceptor document findings and assessments. Particularly weight, I/O, and findings from full head-to-toe assessments 

7/20 P/t on Q1h I/O measurements. Made sure to document amount in foley and document appropriately 

7/27 Monitored and documented I/O for patient who was intubated w/ AKI.  

7/29 Documented hourly vital checks accurately and neatly 

7/31 Documented JP drain fluid Q1h hours and communicated info to HCP and preceptor 

8/2 Patient was suicidal and helped document appropriately for 1:1 observation 

4. Shows evidence of preclinical preparation based on knowledge from nursing physical and behavioral sciences: 

a. Conducts individual investigation to expand knowledge base. 

5 

7/2 P/t with endotracheal tube oxygen levels dropped to 93%. Upon further investigation, I helped suction 2x under 15 seconds. P/t O2 increased to 97% 

7/6 Patient was extubated during my shift and showed evidence of preclinical preparation by understanding the importance of monitoring for hypoxia and respiratory distress during the procedure. 

7/13 My studies on critical care were useful as my patient had an ART line. He needed hourly blood glucose readings and had the opportunity to pull blood from the ART line multiple times along with took blood samples and helped send to lab-I am excited to say I feel fully confident with ART lines now and am also familiar with the importance of keeping the transducer equal to the phlebostatic axis   

7/15 Patient was on diuretic for acute kidney failure. Practiced preclinical preparations based on knowledge from nursing physical and behavioral sciences by monitoring BUN/Creat levels, monitoring hourly I/O’s/weights Q1H, and providing diuretic. 

7/20 P/t on Bipap. I showed preclinical preparation by completing lesson 4.1 on oxygenation. I further expanded my clinical knowledge by discussing this therapy with the RRT. 

7/27 Showed preclinical knowledge in treatment of patient with Guillain-Barre. Helped feed and aid in ADLs as I understood the disease process and that paralysis occurred and could not use her hands effectively. 

7/29 Appropriately assessed pain post myocardial infarction using PQRST scale learned in didactics  

7/31 Showed preclinical knowledge by understanding the importance of preventing clots post surgical recovery. Helped patient ambulate and provided Heparin SubQ 

8/2 Conducted individual research on suicide precautions protocol 

Average Score 

  4.875

ANALYSIS: 

SCORE 

COMMENTS 

1. Clinical decision-making reflects an understanding of the relationships of assessment data to the patient's problem/diagnosis: 

a. States relationships among complex or chronic human need interruptions and situational/setting/system variables. 

b. Makes decisions on culturally sensitive or contemporary health care issues from an understanding of decision theory and current research. 

4.5

7/6 Patient had uncontrolled diabetes (over 300 throughout entire shift). Provided Q1H blood glucose checks, provided continuous Insulin drop, and coordinated with dietitian to change enteral feed to a more diabetic friendly formula. 

7/13 Because p/t had Stage 4 Chronic Renal Disease, he was anemic with Hgb 6.9 and Hct 21.8%. GFR is 9 (<15). Because of this, the doctor ordered a blood transfusion to help with perfusion.   

7/15 Cutting down on unnecessary lab/procedures is a contemporary health care issue frequently discussed in the news. My preceptor and I advocated for our patient and inquired about an upcoming coagulation lab panel that we deemed unnecessary given the patient’s condition. The provider agreed and discontinued the order, ultimately cutting down on care costs. 

7/20 Made culturally sensitive decisions based on the client not being able to speak or understand English. Outside of providing an interpreter, I provided holistic care as well as tuning into her nonverbal communication 

7/27 P/t with AKI (GFR 15). Understood the necessity for dialysis to filter blood and monitor Hgb, Hct, K+, Albumin, phosphorus, and Calcium levels closely post procedure 

7/29 P/t post myocardial had Echocardiogram completed. The therapist showed how the machine work and what he was taking photos of. He showed me where the specific blockages were which aligned with my knowledge of MI pathology.  

7/31 P/t was post surgery and high fall risk. Understood importance of fall risk diagnosis by ensuring she did not fall and provided back gait belt 

8/2 Understood necessary protocol and clinical decision making with patient who was suicidal. Ensured 1:1 observation, and provided alternative and traditional therapies to ensure patient’s safety and well being 

* 2. Identifies priorities requiring nursing action based on the assessment and determines reassessment as indicated: 

a. Recognizes needed changes in healthcare delivery system [HCDS]. 

b. Prioritizes individual and HCDS needs to maximize patient outcomes. 

5 

7/2 Worked shift on weekend and noticed there was an evident lack of staff support (techs/leadership) in building on weekend. A necessary change in HCDS would be to ensure adequate resources are available as there was a a p/t on the floor that had to have the cops called twice and the nurse felt a general lack of managerial support.  

7/6 We received a new admin and the room was not properly ready for her arrival. We were rushed to clean the room while the patient was standing there. I believe there should be a smoother transition for new admins put in place by management to ensure professionalism and patient satisfaction. 

7/13 I had two critical patients that were both intubated. One was in critical condition post brain surgery with hemorrhage near pons. The other had stage 4 chronic renal disease. Both of them had hourly checks, and multiple medications that needed to be administered throughout the day. My preceptor and I created hourly goals and helped her complete all tasks based on priority. We took into consideration ABCs and safety protocols. 

7/15 P/t’s O2 stats lowered to 85% after ambulating. We increased her O2 to 100% and was a effective intervention as the patient was prioritized 

7/20 After helping /t with COPD with Bipap and her O2 sats increased to 100, I ensured she was comfortable by providing a table covered with a pillow to help her lean in tripod position to help with breathing. I then lowered the lights and ensured therapeutic milieu  

7/27 Prioritized p/t needs by giving meds with breakfast. P/t with dementia refused to eat or drink in the last 24 hours or take her medications. When I attempted to provide medication in applesauce, she spit it out. Later that day, she had more energy and requested food. I provided her medications at that time and she consumed fully. 

7/29 Recognized a necessary change in the healthcare system in regards to transfers. We received a patient from ER and did not receive a formal report. There seems to be a need for more effective communication between departments 

7/31 Patient given albuterol nebulizer due to decreasing O2 levels (COPD) 

8/2 Identified a need for more mental health professionals within a traditional hospital setting. Many of the patients are provided traditional care but were in need of therapy due to their mental states  

* 3. Formulates nursing diagnosis based on assessment data: 

a. Used in a chronic or complex human need disruption as indicated. 

b. Recognizes nursing’s contribution potential to recipients. 

5 

7/2 Diagnosed p/t with risk for impaired airway exchange as she had a hx of COPD and was recently extubated from endotracheal tube 

7/6 The first half of the shift the patient was not ready for extubation as she was unable to respond to stimulation or turn/lift her neck. She was at risk for ineffective coping as her blood pressure was also high and was not fully alert. 

7/13 My patient was diagnosed with deficient fluid volume r/t massive blood loss. She was admitted to the ICU post surgery after suffering a brain hemorrhage during surgery and at risk for hypovolemic shock. We monitored her neuro status and provided fluids throughout the day. 

7/15 P/t was diagnosed with risk for adult fails in relation to impaired mobility post MI. We provided her with a Fall Risk bracelet and put on the bed alarms to ensure her safety. 

7/20 Decreased Activity tolerance r/t imbalance between oxygen supply and demand. P/t with COPD O2 would drop into low 80s every time she ambulated to bathroom. We recommended she be put on foley catheter to ensure rest. Doctor agreed and inserted foley. 

7/27 Risk for Aspiration r/t Guillan-Barre Syndrome. Made sure to cut food in small pieces and help feed as she had paralysis in her hands. 

7/29 P/t post myocardial infarction at fall for risk. I made sure to put his bed alarm on as he attempted to get out of bed without calling a nurse first despite explicit directions to do so. 

7/31 P/t diagnosed with high fall risk post spinal fusion 

8/2 Diagnosed suicidal patient with situational low self-esteem r/t guilt, inability to trust, feelings of worthlessness or rejection  

Average Score  

 4.83

PLANNING: 

SCORE 

COMMENTS 

* 1. Formulates appropriate and measurable goals for self and patient: 

a. States realistic goals for a variety of   patients.   

b. Considers spiritual, ethnic, socioeconomic, etc. factors in goal setting. 

4.5 

7/2 P/t will remain calm post extubating. O2 stats will remain about 95% on RA by e/o shift. Goal met. 

7/6 P/t will be successfully extubated by e/o shift. Goal met 

7/13 My goal for myself was staying informed on the patient’s status and effectively communicate with the family members in a therapeutic manner.  

7/15 P/t requested wanting to see the chaplain and was made a goal for the day. While my preceptor and I met our highest priorities first for her care, the chaplain was able to visit with the p/t by e/o shift. 

7/20 P/t who does not speak English will understand all procedures diagnoses and will have all questions answered by e/o shift 

7/27 The goal for my patient today is successful extubation. There was one attempt to extubate a week prior but it was unsuccessful. He is stronger now so a reattempt is recommended. 

7/29 P/t will have Foley catheterization removed prior to e/o shift-goal met. 

7/31 Considered spiritual factors in goal setting and coordinated a meeting with chaplain  

8/2 Patient with suicidal ideation will report improved mood by e/o shift 

* 2. Plans care in a systematic, logical, organized manner: 

a. Plans appropriate level of care according to identified acute care needs. 

5 

7/2 I had two patients and was successfully able to prioritize orders based on acute needs. For example, I prioritized taking ordered blood work on one patient before ordering lunch for the second patient. 

7/6 In the morning I performed a full head to toe assessment, reviewed her labs and medication orders, then effectively planned interventions based around highest priorities. These included monitoring her blood glucose levels, ensuring a patent airway, and providing blood pressure/insulin medications. 

7/13 With multiple medications, blood glucose checks, and position changes, my preceptor and I planned our day in a systematic and logical manner. She effectively delegated tasks to me to help and overall the day ran smoothly. 

7/15 I had two patients. One stable and recovering from an MI, and another with COPD. I was able to effectively prioritize my interventions based on any acute or new onset of symptoms that arise throughout the day. 

7/20 P/t had C Diff and implemented contact precautions/isolation. I made sure to wear gloves and a gown over my clothing when entering the room and wash my hands with soap and water when leaving the room 

7/27 After performing my head-to-toe assessment and helping discuss the patient’s status in rounds, I prioritized the needs of my patient with AKI as his immediate needs were more acute compared to my second patient with Guillain-Barre. Once I provided his morning meds under supervision of my preceptor, I documented his vitals and then fed breakfast to my other patient 

7/29 Had two patients. One recovering from neuro surgery and another recovering from a MI. I appropriately prioritized patient needs on acuity level throughout the day.  

7/31 Provided patients with most acute needs first utilizing ABC’s and prioritization skills 

8/2 P/t with ARDS was often prioritized over my other patient with suicidal ideations as their respiratory needs were more acute.  

3. Plans health teaching based on identified learning needs and readiness of patient: 

a. Acute care education needs are addressed considering ethnic, socioeconomic, etc. factors 

5 

7/2 P/t refused to be moved for peri care and had an indwelling catheter. I provided education that peri care was necessary to prevent infection 

7/6 P/t’s daughter kept wanting to watch TV and listen to music, and had the lights on. I educated that the patient needed to remain in a calm, quiet environment to ensure she was not stimulated prior to extubation 

7/13 The patient’s daughter was confused as why her mom needed to be continually sedated post surgery/hemorrhage. We helped explained that this would help keep her comfortable and allow her body to heal. 

7/15 Found fall risk p/t at bedside standing up. I quickly helped her lay back in her bed and provided education about the need to contact a nurse before standing up to ensure her safety. 

7/20 P/t with COPD did not understand how to use incentive spirometer. I helped explain via teach back method and emphasized the importance of using it Q2H 

7/27 Discussed and helped educate the family of my patient on the process of extubation. Answered what we would be monitoring to gauge success and our overall goals for the day post procedure. 

7/29 P/t attempted to order a cheeseburger post myocardial infarction. I educated him that he needs to remain on a heart healthy diet and outlined foods that were better choices and provided reasoning why. 

7/31 Provided p/t education by expressing they would be unable to attend physical therapy if pain medication was given via IV prior. 

8/2 P/t’s socioeconomic needs were addressed as she had no health insurance and needed to be transferred to a mental health facility. Collaborated with case worker to identify a plan of care. 

4. Communicates clearly regarding nursing care plan with all appropriate individuals: 

a. Coordinates among health care workers and patient in planning for meeting health needs 

5 

7/2 Coordinated w/ preceptor and respiratory therapist on providing O2 care for p/t with COPD and helped plan and meet O2 needs pre and post endotracheal tube extubation  

7/6 Communicated with daughter about the extubation process and what to expect. I did my best to answer her questions and discuss our priorities for the day. 

7/13 Since I helped draw blood multiple times, I coordinated with lab on sending blood samples and helped my preceptor with communication with them throughout the day.  

7/15 Helped preceptor during rounds with HCP explain patient updates and clarified goals for the day. 

7/20 Coordinated with other healthcare professional (RRT and physician) to ensure my patient with COPD’s needs were met. I advocated for her needs and communicated any acute changes. 

7/27 Coordinated with physician, dialysis RN, and Respiratory Therapist to plan patient’s extubtion.  

7/29 Coordinated with ER for patient transfer with myocardial infarction. Also worked directly with therapist and prepared patient for echocardiogram 

7/31 Communicated goals for patient with COPD. Encouraged hourly use of incentive spirometer and the importance of calling the nurse when having to use the restroom. 

8/2 Communicated directly with two patients on the day’s plan of care, answered questions appropriately. Both were cooperative and understood interventions via teach back method 

Average Score  

4.875 

IMPLEMENTATION: 

SCORE 

COMMENTS 

* 1. Utilizes effective and appropriate verbal/non-verbal communication skills: 

a. Adapts communication according to situation, setting, patient, and role function. 

b. Approaches patient in a non-threatening, non-discriminatory way. 

5 

7/2 Provided therapeutic communication to p/t and family. Actively listened to family members concerns and encouraged them to express their feelings. 

7/6 Prior to extubation, we stopped her sedation meds and assessed her LOC Q30min by asking patient to blink, squeeze hand, and move foot. I spoke in a polite and direct voice and provided therapeutic communication. 

7/13 Ensured I was careful with intubated patient and upheld safety measures while helping reposition. I helped keep her cords untangled and provided pads around her restraints to ensure there was no skin irritation. 

7/15 When patient with fall risk was found standing at the side of bed, I calmy but swiftly approached the patient to help her back into bed and explained the importance of calling a nurse prior to getting up in a non-threatening way. 

7/20 Approached patient who did not speak English in a non-threatening, non-threatening, non-discriminatory way. Ensured she was comfortable and that her needs were met. 

7/27 Adapted communication and style to patient with dementia. Provided therapeutic communication and provided evidence-based practice to ensure her needs were being met with limited verbal communication ability. 

7/29 Actively listened to patient post MI. He was understandably distressed and sat with him and provided encouragement when appropriate 

7/31 Approached patients in calm, professional manner and answered all questions  

8/2 Approached patient with suicidal ideations in a non-threatening way and used therapeutic communication when speaking with her. 

* 2. Provides direct patient care in a safe, accurate, organized manner: 

a. Applies time management concepts. 

b. Employs principles of delegation and prioritization. 

c. Uses change theory and processes to implement alternatives to previously identified activities, when appropriate. 

d. Safely, competently and responsibly implements novice nurse role that incorporates research and theory in accordance with standards of practice. 

5 

7/2 Provided timely care in accordance with doctor’s orders. Vitals, restraint checks, and medication administration were completed on time. 

7/6 Ensured room was clean and organized. Changed bedding and coordinated with UAP to help with repositioning Q2H to prevent pressure injury. 

7/13 With two critical patients, I worked closely with my preceptor to ensure my delegated tasks were safe and completed correctly. I incorporated research and theory in accordance with standards of practice. 

7/15 Provided safe and competent care in all responsibilities that my preceptor delegated to me throughout the day 

7/20 Applied time management by meeting my patient’s most acute needs first and ensured they were stable before moving on to next task. 

7/27 Safely, competently, and responsibly implemented research and theory in accordance with standards of practice by utilizing lessons learned about neurological disorders and how to successfully a patient for increased ICP 

7/29 Applied time management concepts by ensuring patient was well fed and dressed prior to physical therapy 

7/31 Applied time management concepts by giving all meds and dressing patient prior to occupational therapy session 

8/2 Provided safe, direct patient care by helping preceptor transfer patient from ICU to get her CT Scan. Safely transferred patient from bed to table and ensured all lines were in tact and oxygen was hooked up appropriately. 

* 3. Administers medications safely according to established procedure: 

a. Applies principles of medication administration to a variety of settings. 

5 

7/2 Provided safe medication administration by conducting three medication checks and ensured it was the right dose, route, and patient 

7/6 Provided all medications safely and ensured each med was for the right patient, the right route/dose and monitored how the patient tolerated. I also made sure the meds provided via IV push were compatible.  

7/13 Helped preceptor provide all medications for both patients safely and administered via PIV, NG tube, Sub Q IM, and used infusion pump for IV medications. 

7/15 Safely administered heparin Sub Q, two inches from the umbilical by pitching skin. Area was cleaned and needle was disposed safely. 

7/20 Researched drugs I was unfamiliar with and looked up their drug classification and mechanisms of action in relation to the patient’s medical diagnoses. 

7/27 Provided all medications (oral, G-Tube) safely and conducted three med checks prior. Monitored for adverse effects. 

7/29 Inquired with preceptor on a few drugs I was unfamiliar with prior to administering to patient to ensure safety 

7/31 Provided Heparin safely by sanitizing with alcohol and pinching skin during injection. Disposed of needle safely in sharps container 

7/13 Administered all medications safely using three medication checks, and discussed each med with patient prior to administering 

* 4. Communicates accurately, verbally and in writing (charting and reporting): 

a. Documentation is clear, accurate and comprehensive and reflects conformance to institutional or other specified protocol. 

4.5 

7/2 Completed Journal 1 which outlined a comprehensive outline of the patient care I provided throughout the week. 

7/6 Provided professional communication with patient and her daughter throughout my shift. My journal submitted documented a thorough overview of my interventions throughout the day clearly and accurately. 

7/13 Communicated accurately and verbally and helped provide information of both of my patients during shift change. 

7/15 Helped complete paperwork for rounds with HCP. Documentation was clear, outlined neatly, and relevant to the patient’s care. 

7/20 Communicated effectively during shift and provided accurate information regarding the patient’s condition 

7/27 Documented and recorded hourly weights and I/O for patient with AKI 

7/29 Appropriately documented correct information about patient assessment and learned new charting methods from my preceptor 

7/31 Documentation of hourly JP tube drainage is organized and accurate 

8/2 1:1 Observation was clearly documented in a timely manner according to hopsital protocol 

5. Collaborates with patient/family/health care team and other appropriate individuals: 

a. Determines referral sources and accurately and clearly communicates information to promote continuity of care. 

b. Supervises and coordinates delivery of patient’s care. 

5 

7/2 Collaborated w/ health care team to transfer patient from ICU to Med-Surge floor 

7/6 Worked closely with the pulmonary provider and respiratory therapist to decide if patient was ready to be extubated  

7/13 The HCP discussed hospice care for my patient with lung cancer with metastasis in the brain. I observed my preceptor provide information on hospice care and helped comfort and console patient’s family. 

7/15 Supervised and coordinated delivery of patient’s care when patient’s daughter wanted to help with patient’s morning ADLs 

7/20 Supervised and coordinated delivery of patient’s care and helped my preceptor with all tasks that she delegated directly to me. Provided a verbal report after each task was completed and asked questions that I had. 

7/27 Coordinated delivery of patient’s care with dialysis RN 

7/29 Determined referral source for a nutritionist as requested by the patient recovering from MI 

8/2 Collaborated with case worker to figure out transfer plan for patient with no insurance needing to be transferred to a mental health facility 

Average Score  

 4.9

EVALUATION: 

SCORE 

COMMENTS 

1. Uses evaluation appropriately in the nursing process (utilizes data to validate if identified goals are met): 

a. Evaluates factors facilitating or hindering the patient’s ability to meet their health needs. 

5 

7/2 Evaluated interventions appropriately, specifically with medication administration. Provided Lisinopril for HTN and documented baseline 142/94 w/ goal of BP below 130/85 Q2H. Goal met. 

7/6 Post extubation, p/t was unable to move the right side of her body. This is a common finding from the hemorrhage in her brain post surgery. I evaluated her case and researched the need for long-term rehabilitation post discharge. This was effectively communicated by my preceptor to the patient directly and her daughter. 

7/13 Because the patient had stage 4 chronic disease, it disables the body to effectively perfuse and stabilize. With a robust amount of other health issues, the CKD inhibits the patient’s ability to meet their other health needs. 

7/15 After providing diuretic, we monitored BUN/Creatinine level to ensure the kidneys were not overloaded. 

7/20 Used evaluation appropriately in the nursing process and utilized data to validate if identified goals were met. For example, patients blood glucose levels were 65 and administered Glucagon. I then reassessed her blood sugar within 30 minutes and her blood sugar was 92 

7/27 My patient with Guilian-Barre is unable to meet her health needs independently due to her ascending paralysis. Evaluated her   

7/29 Evaluated patient’s ability to void post removal of Foley Catheterization. Patient was able to successfully void and meet their elimination needs. 

7/31 P/t unable to attend therapy due to pain levels post surgery. Provided pain medication and provided passive ROM exercises. 

8/2 Utilized the depression/self-harm screening to along with the C-SSRS and safe environment check list to evaluate if therapeutic methods were helpful 

* 2. Evaluates effectiveness of specific interventions: 

a. Demonstrates responsibility and accountability in evaluation of nursing care provided. 

5 

7/2 P/t pulled NG tube out. Helped preceptor reinsert and called Xray to confirm placement in stomach. Intervention was successful. 

7/6 Once patient’s enteral feed was changed to a more diabetic friendly formula after working directly with the dietitian, her blood glucose levels finally dropped below 300 just before end of shift. 

7/13 This morning my patient with CKD also had Type II Diabetes. His blood glucose was 326 and had a goal of lowering to under 200 by e/o shift. Our last blood glucose test at 1800 was 174 so were happy to meat our goal. 

7/15 P/t requested chaplain. I demonstrated responsibility and accountability by ensuring I would call them and provided updates on when they could expect her visit.  

7/20 Demonstrated accountability by completing all tasks delegated to me by my preceptor and also followed the ethical principal of fidelity by keeping my word of when I would return or follow up with patients next. 

7/27 P/t was successfully extubated. Provided 100% O2 and continued to provide suction to help remove secretions. Encouraged coughing. 

7/29 Demonstrated responsibility as I recommended to hold the patient’s beta blocker since his BP was low 

7/31 P/t w/ COPD O2 levels decreased to 84%, provided albuterol via nebulizer and monitored until O2 sat was above 90% 

8/2 Assessed patients anxiety level and mood after taking sertraline (SSRI) Q1H after administration 

3. Develops alternate interventions and goals when appropriate:  

a. Reevaluates goals for appropriateness if desired outcome is not achieved. 

b. Performs ongoing evaluation of   

own professional nursing practice    

5 

7/2 P/t refused medication and stated they tasted gross. I recommended crushing them and putting in vanilla pudding which she then agreed to. Alternative method was appropriate for desired outcome of p/t consuming meds on time. 

7/6 P/t’s blood glucose level was not dropping below 300 despite multiple changes to her medications. After reevaluating with the provider and dietitian, we updated the plan which seemed to be effective prior to the end of shift 

7/13 Since both of my patients were in critical conditions, I effectively performed ongoing evaluation of my own professional nursing practice and made sure to ask my preceptor questions on specific nursing techniques and how various lab values and medications would help their various health conditions in the big pictures. 

7/15 Performed ongoing evaluation of own nursing practice by discussing drugs that were unfamiliar to me with my preceptor to gain a better understanding of their action and how it was relevant to their treatment. 

7/20 Performed ongoing evaluation of medication administration, learning from my preceptor and learning new techniques to ensure patient safety. 

7/27 Evaluated actions and prioritization chosen for all goals and interventions for the shift. Discussed with preceptor on methods of prioritization. 

7/29 Developed alternate form of therapy after p/t was unable to ambulate. Helped with passive ROM exercises and repositioning p/t Q2H to improve circulation and prevent pressure injuries. 

7/31 Evaluated technique to help ambulate patient to better protect back if fall were to happen 

8/2 Reevaluated goals for therapeutic/alternative methods for patient with suicidal ideation. Developed alternate methods by providing a calm environment (dimming lights, turning television off) after sunlight and noise from television seemed be overwhelming 

Average Score 

5 

Clinical Practicum Evaluation 

 24.48/5 =

4.896 =

96%

Clinical Practicum Evaluation (70% of grade): 96%

Shadow Health (15% of grade): 100%

Canvas Assignments (15% of grade): 99.01%

  FINAL COURSE GRADE: 97.05% = A