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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

S: Desired Outcomes
‘ I make slight Activity 1. Check vital signs before
effort I feel tired Goal Met: After 8 hou
Intolerance rt and immediately after 1.Orthostatic hypotension can occur
already. “ After 8 hours of nursing of nursing intervention
Generalized activity. with activity because of medication
fatigue intervention the patient had:
weakness effect (vasodilation), fluid shifts
evidence by Participated in
(diuresis), or compromised cardiac desired activities;
patients
 Participate in 2. Document pumping function. meet own self-
complain of
O: fatigue desired cardiopulmonary care needs, with
SOB with activities; response to activity. 2. Compromised myocardium and/or gradual less
exertion meet Note tachycardia, inability to increase stroke volume assistance
↓ SpO2 own self-care  dysrhythmias, dyspnea, during activity may cause an immediate
Tachycardia Achieved
needs. diaphoresis, pallor increase in heart rate and oxygen measurable increa
demands, thereby aggravating weakness in activity toleran
 Achieve
measurable 3. Assess for other causes and fatigue. evidenced by
Vital signs: increase in of fatigue (treatments, reduced fatigue an
activity 3. Fatigue is a side effect of some weakness and by
Temp: 36.6 pain, medications).
Bp: 163/136 tolerance, medications (beta-blockers, vital signs within
mmHg evidenced by tranquilizers, and sedatives). Pain and acceptable limits
P:111 reduced stressful regimens also extract energy during activity.
RR: 22bpm fatigue and and produce fatigue.
Spo2:90%-910% weakness and 4. Assess patient’s general
room air by vital signs 4.To note for any abnormalities and
condition
within deformities present within the body
acceptable
limits during 5. Evaluate accelerating
activity intolerance. 5.May denote increasing cardiac
activity.
decompensation rather than
overactivity.
6. Provide assistance with
self-care activities as 6.Meets patient’s personal care
indicated. Intersperse needs without undue myocardial
activity periods with rest stress and excessive oxygen
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demand.
periods.

7. Assist patient with

ROM exercises. Check
regularly for calf pain
and tenderness. 7.To prevent deep vein
thrombosis due to vascular

8. Adjust client’s daily

congestion.
activities and reduce
intensity of level.
Discontinue  activities
that
cause undesired 8.Prevents straininga nd
psychological changes
overexertion which may aggravate
9. Instruct client in
symptoms
unfamiliar activities and
in alternate ways of
conserve energy
10. Encourage patient to
have adequate bed rest
and sleep 9. Conserves energy and promote
safety
11. Provide the patient with
a calm and quiet
environment
10.Relaxes the body and promotes
comfort
12. Assist the client in
ambulation

13. Note presence of factors 11.Provides relaxation

that could contribute to
fatigue

14. Ascertain client’s ability

to stand and move about 12.Prevents risk for falls that could
and degree of assistance
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needed or use of lead to injury
equipment
15. Give client information 13.Fatigue affects both the client’s
that provides evidence actual and perceived ability to
of daily or weekly
participate in activities
progress
16. Encourage the client to
maintain a positive
attitude 14.Determines current status and
needs associated with participation
17. Assist the client in a
in needed or desired activities
semi-fowlers position

18. Elevate the head of the 15.Sustains motivation of client

bed

19. Assist the client in

learning and 16.Enhances sense of well being
demonstrating
appropriate safety
measure
20. Instruct the SO not to 17.Promotes easy breathing
leave the client
unattended
21. Provide client with a
positive atmosphere 18.Maintains an open airway

22. Instruct the SO to

monitor response of
patient to an activity and 19.Prevents injuries
recognize the signs and
symptoms

20.Avoids risk for falls

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21. Helps minimize frustration and
rechannel energy

22.Indicates need to alter activity

level

/2 /2 /2 /2 /2
Total Marks : / 10
Signature of the Preceptor: _________________________
Date : ________________________