Reflection On Clinical Assessments

1. What have I done well?

What I do well is gather patient information properly from the Holy Spirit computer system. I am great at performing vital signs and collecting report from the night shift nurse. I am always on time before the start of my shift. I understand how to properly prepare before entering a room on isolation precautions. I always have a positive attitude when I step foot in the hospital. I have recently developed more therapeutic techniques to communicate with my patients. I have improved with organizing myself as well as establishing a sufficient routine. I can develop interventions for my patients based on the information I received from my assessment. I am proud of myself, because I can see my growth and improvement since

the first day of clinical.

2. What could I have done better?
What I can do better is knowing what labs are important for my patient’s medical diagnosis.

I need to improve my skills with developing nursing diagnosis, interventions, and outcomes. I need more practice using SIM Chart. I also should try to remember the important IV fluids that my patient is receiving that day. I feel as though, I can improve my occupied bed making skills as well as bathing, because I tend to struggle at times. I could have organized more time during clinical to listen to lung sounds and heart sounds with my instructor. Furthermore, I know that the rapid assessment is important because I need to establish a baseline for my patients, but I tend to hesitate if my patient has already started eating breakfast.

3. How can I continue to improve my performance in this area?

I can continue to improve my performance by practicing my assessments. I also need to practice my occupied bed making. I should review my patient information several time before entering the hospital. I need to take advantage of fitting in assessment time with my instructor. I should look up nursing diagnosis, interventions, and outcomes before clinical. Moreover, I need to figure out the abnormal lab values that are associated with my patient’s diagnosis and grasp and understanding of what is going on with my patient.

4. What do I need to make this happen? (I.e. resources/education or support I could access to help me build this

skill)

I should review ATI before clinical. I need to take advantage of the programs installed on the computer system to figure out the important lab values associated with my patient’s diagnosis. I should look in my care plan book to help figure out nursing diagnosis, interventions, and outcomes. I should take advantage of the extra lab time available throughout the week to practice my assessments.

5. How will I know I have improved? (What is my measure of success?)
I will know I improved when I am able to perform a complete head to toe assessment without missing anything. I will also know I improved with my organization skill, when I fit my professor in my schedule. Also, when I am able to come up with nursing diagnosis, intervention, and outcomes without looking in the book. I would know I improved when I can interpret the abnormal labs and have an idea of why this may be happening to my patient. Moreover, I will see improvement, when I can remember what drugs my patients are taking and why they are taking this drug. Overall, I know that taking advantage of this clinical time will benefit me in the near future. I understand that my professors are here to help with providing skills, but it is my job to take advantage because nursing is an autonomous job. Every day, I step foot in the hospital I am constantly thinking can I see myself working here. I learned from my observation that there they are nurses who seem to love their jobs and others not so much. For me, each day I step for in a hospital I know I made the right career path.