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    Log Sheet 4

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    SHAFIQ
    The document details a clinical log sheet for a student nurse including patient details, diagnosis, lab investigations, interventions, and teaching provided for a patient with end-stage renal disease and diabetes admitted with complaints of weakness and low blood pressure. Key details include the patient's history, examination findings, labs showing renal dysfunction and elevated cardiac markers, management including medications and monitoring, and discharge teaching.

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    © All Rights Reserved
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    Log Sheet 4

    Uploaded by

    SHAFIQ
    16 views4 pages
    The document details a clinical log sheet for a student nurse including patient details, diagnosis, lab investigations, interventions, and teaching provided for a patient with end-stage renal disease and diabetes admitted with complaints of weakness and low blood pressure. Key details include the patient's history, examination findings, labs showing renal dysfunction and elevated cardiac markers, management including medications and monitoring, and discharge teaching.

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    The document details a clinical log sheet for a student nurse including patient details, diagnosis, lab investigations, interventions, and teaching provided for a patient with end-stage renal disease and diabetes admitted with complaints of weakness and low blood pressure. Key details include the patient's history, examination findings, labs showing renal dysfunction and elevated cardiac markers, management including medications and monitoring, and discharge teaching.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    16 views4 pages

    Log Sheet 4

    Uploaded by

    SHAFIQ
    The document details a clinical log sheet for a student nurse including patient details, diagnosis, lab investigations, interventions, and teaching provided for a patient with end-stage renal disease and diabetes admitted with complaints of weakness and low blood pressure. Key details include the patient's history, examination findings, labs showing renal dysfunction and elevated cardiac markers, management including medications and monitoring, and discharge teaching.

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    Clinical Log Sheet

    Student Name Uzma Bibi

    Clinical Hours/week: week 1


    Day 2
    8 hours
    Morning Shift

    Date: From 30-11-23 To 30-11-23

    Preceptor Name: Ms. Sehrish Sajjad

    Placement: IM-P3

    Objectives:

    1. introduction to ward management (Head Nurse) and a comprehensive orientation to the ward.
    2. Establish connections through meet-and-greet sessions with assigned staff, articulating our clinical
    objectives.
    3. Choose patients, introduce them, and explain the rationale behind history-taking and assessment.
    4. Perform exhaustive systemic and head-to-toe assessments for each patient.
    5. Distinguish and address patient needs through customized management strategies.
    6. Deliver education tailored to individual patient needs, employing formal and informal methods.
    7. Integrate pertinent laboratory and investigative findings about the patient's health status.
    8. communicate both pharmacological and surgical management plans to patients.
    9. Implement care practices firmly rooted in evidence-based approaches, seamlessly blending
    theoretical knowledge.
    10. Undertake the responsibilities characteristic of an advanced practice nurse throughout the continuum
    of patient care.
    Patients Details & Demographics and Chief Complain

     A patient named Thebo Naseer Ahamd, 45 years old, under the care of Dr. Amber Sabeen, with
    admission dates 25-11-23, came into the ER with a complaint of general body weakness and low
    BP. According to the patient attendant at home, he was in his usual state of health when he
    developed a low BP of 55/60 and Pulse of 60bpm on the following day; he became cold clammy
    had difficulty in breathing and orthopnea.
     On assessment, HR= 66/min, SPO2=96%, RR=26/min, BP=122/76.
     Bilateral Crept and wheezing were present on auscultation; the abdomen was soft and non-tender,
    and bowel sounds were in the normal range, S1 and S2 sound positive.
    Diagnosis
     End-stage renal disease
     Diabetes Mellitus and hypertension

    Lab Investigation (Relevant)


     MRI showed Encephalomalacia and gliosis in the right occipital lobe secondary to
    old ischemia no acute infarct or intracranial hemorrhage is detected.
     US-LIVER/G.BLADDER Partially contracted thick-walled gallbladder with tiny
    sludge ball as detailed above. Minimal bilateral pleural effusion.
     US Kidneys showed Grade I renal parenchymal disease. No sonographic evidence
    of obstructive uropathy
     Chest X-ray shows Slight interval improvement in pulmonary edema and improved
    aeration in bilateral lung fields.
     ECG: Poor R wave progression Q wave in lead AVF,V5, V6
     On arrival in the ER, the labs were
     Hb  11.9
     MCV  97.3 K 7

     WBC  11.9 Cl 98

     Neu  81.9 Cr 18.3

     Lym  7.4 HbA1c 6.6

     Plt 171 Na 131

      TropI 1770

     

     Current Labs
     Na  140
     K  4.2
     Cl  97
     Cr  8.6
     TropI  2157
     
     
     
     
     Hb  11
     WBC  10.3
     Neu  81.5
     Lym  7.4
     Plt  149
     ABGS
     PH  7.15
     PCO2  32
     PO2  36
     HCO3  10.9
     CA  1.5
     O2 SAT  47.2

    Interventions- Pharmacological

     Aspirin75mg
     Clopidogrel 75mg
     Ceftriaxone 2000mg
     Humalog 2IU
     Calcium Acetate 2 tabs
     Atorvastatin Calcium 20mg
     Pregablin 50mg
     Glargine 20U
     Omeprazole 40mg

    Non-Pharmacological
     Planning to mobilize up to chair.
     Discharge teaching given as patient will discharge after 24 hrs.
     Fluid Management.
     Blood Pressure Monitoring.
     Regular Follow-up and Monitoring.

    Teaching Provided (if done)

     Discharge teaching given and home health care services explained to patient
     Importance of monitoring fluid intake from both beverages and foods.
     Importance of regular blood glucose monitoring.
     Medication adherence and insulin administration.
     Recognizing and managing hypo/hyperglycemia symptoms.
     Maintain blood pressure within the target range to prevent cardiovascular complications.

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