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POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA

Log Book Case Debriefing with the Preceptor
Name of the Trainee : SCFHS Reference No : Year : D1D2 Case Category:

Date: Area
Assessment Diagnosis Planning Nursing Interventions/ Rationale Evaluation

In 4 hours
S: nursing
I have edema on his lower right leg) Excess fluid intervention: Weigh daily; Utilize same Daily body weight is a good Goal Met: Afte
as verbalized by the patient volume related to weighing scale every day, with indicator of hydration status. A 4 hours of
compromised the patient nursing
the same clothing and same weight gain of more than 0.5
regulatory will display intervention
time. kg/day suggests fluid the patient
mechanism with stable
changes in weight, vital retention. noted
Objective :
Lower limb edema and fatigue. hydrostatic or signs within
oncotic vascular patient’s Patient’s
pressure and normal edema
Vital signs : increased range, and Strictly monitor and decreased.
T:36.9 activation of the nearly
record intake and output. Accurate measurement
Bp:129/69mmgh rennin- absence of Patient
angiotensin- edema. determines fluid balance.
P:79 bpm achieved ide
aldosterone
RR: 19bpm body weight
system.
without
Spo2: 99%
Level of excess fluids
Physical Assessment : Determine potential sources of
Prioritization:
CNS :patient is conscious alert excess fluid (e.g., food, Identification of other sources
HIgh
, GCS : 15\15 , normal head medications used) of excess fluid aids in the
structure , pupil reacting with therapeutic regime
light
Cardiovascular :
heart sound normal S1-S2 ,
lower limb edema . Amount of allowed fluid intake
Advised to limit fluid intake as
Respirator : Lungs sound clear is determined based on child’s
andequal . ordered weight, urine output and
GIT :Nausea , vomiting , no response to treatment.
abdomen distention and
noTenderness .
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GUT : normal voiding .
With foamy urine .
Skin : color within normal
level , skin intact .
Psychosocial :behavior wihin
normal level .

Monitor urine specific gravity. Measures the kidney’s ability

to concentrate urine.

Edema occurs primarily in

Assess skin, face, dependent dependent tissues of the body.
areas of edema It will serve as parameter the
severity of fluid excess.

Monitor heart rate and blood Tachycardia and hypertension

pressure. can occur because of failure of
the kidneys to excrete urine.

May reflect fluid shifts and

Assess level of consciousness; electrolyte imbalances.
investigate changes in
mentation, presence of
restlessness.
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COLLABORATIVE: Provide assessment of the

progression and
Monitor laboratory and management of the
diagnostic studies. dysfunction.

Administer diuretics as To promote adequate urine

prescribed. volume that aids in prevention
of further edema.

Administer corticosteroid (e.g.,

prednisone) as prescribed.

Corticosteroid therapy
continues until the urine is
protein free and continues to
be normal for 10 days to 2
weeks. A therapeutic response
usually occurs in 1 to 3 weeks.
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Total Marks : / 10
Signature of the Preceptor: _________________________
Date : ________________________