Professional Documents
Culture Documents
Log Book Critical 2023-2024
Log Book Critical 2023-2024
Log Book Critical 2023-2024
2023 - 2024
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Critical and Emergency Department
Student Name:
Year of Graduation:
Log book
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Logbook Content
Introduction
Purpose of logbook
Logbook Instructions
Course Specification
Case Studies
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INTRODUCTION
This logbook is designed to provide a guideline for nurse students during the internship
program.
The logbook includes a list of major skills/procedures to ensure the achievement of clinical
objectives of each specific unit.
Each specific procedure checklist differs from one hospital to another thus refer to policy
& procedure for details.
The student will acquire the competency of the task by observing the preceptor/staff nurse
and practice them several times.
The log book is kept by the Nurse Intern. After completion of task, it is responsibility of
nurse intern to check and to take the signature from immediate staff nurse trainer.
Purpose of the log book:
The course aims to help nursing students to receive training in different intensive care units which
enrich their knowledge
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B.2 Differentiate between pathophysiology, clinical manifestations, diagnostic
studies and management of different critical conditions.
B.3 Develop critical thinking and problem-solving abilities in prioritizing,
planning, providing and evaluating nursing care for different critical conditions.
B.4 Select appropriate nutrition for different critical care conditions.
B.5 Interpret critical ill patients' parameters to identify appropriate
management.
B.6 Design health teaching plans for critical ill patients with different medical
diagnosis.
B.7 Utilize nursing process as a framework for planning, implementing and
evaluating critical ill patient care.
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Logbook Instructions
Personal Information:
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COURSE SPECIFICATION
1. BASIC INFORMATION:
Course Title : Critical Care Nursing Practical
Course Code : NUR312
Credit Hours : 4 / week
Course Level : First year
2. COURSE DESCRIPTION:
The aim of this course is to help nursing students to receive training in different
intensive care units, which enrich their knowledge.
4. INTENDED LEARNING OUTCOMES OF COURSE (ILOS)
By the end of this course, each student will be able to:
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practice.
a.7. Prioritizing skills in order to identify health problems in the
critical phase of disasters
4.b. Intellectual Skills المهارات الذهنية
b.1. Utilize mechanical ventilation to identify patient health
problems for patients with cardiovascular and critical life
threatening problems.
b.2. Classify life threatening condition in critical department
b.3. Identify the appropriate action for the critical situation
b.4. Compare between types of drainage
b.5. Compare and contrast different critical patient conditions
based on functional body systems and priority of emergency care
b.6. Measures accurately the effect of nursing actions which can
be reflected by vital signs or improving of patients' health
condition.
b.7. Writes accurately the implemented nursing actions which
should be complete, precise, accurate, and relevant.
4. c. Transferable Skills المهارات المهنية
c.1. Utilize evidence-based practices in application of critical
nursing care.
c.2. Utilize different informational resources in critical nursing
c.3.Employ accurate documentation while providing and/or
managing for client needs
c.4. Utilize critical thinking and problem solving in planning and
implementing nursing care for individuals, families, and groups
c.5. Demonstrate skills in handling various equipment's utilized in
critical care settings
c. 5. Demonstrates ethical principles and legal concepts related to
critical care nursing.
C.6. Apply basic principles of health teaching of patient.
4.d. General Skills المهارات العامة
d.1. Demonstrate decision-making skills in critical situations.
d.2. Develop leadership skills
d.3. Apply appropriate nursing management principles based on
assessment findings
d.4. Communicate effectively with health care team, patient and
the patient’s support network.
d.5. Produce safe and secure environment.
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5. COURSE OUTLIN
COURSE CONTENTS
7. EVALUATION
Evaluation Weight
Periodic Exam (Quizzes) 40%= 80 grades
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8.TIME
Head of department:
Lecturer: …………………………..
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Candidate’s Personal Information
Candidate's Name:
Academic Card Number:
License Number:
Cellular Phone
Number:
E-mailAddress:
Address:
Date of Registration: / /
Supervisor's Name:
Candidate's Signature:
Supervisor's Signature:
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Assessment Sheet for Critical Ill Patient ( / 10 marks)
Neurological ( /4)
Modified GCS
Activity Score Activity Score Activity Score
A. Eye opening B. Verbal response D. Motor response
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GCS= A+(B or C)+d 13-15 conscious 9-12 semiconscious 3-8 unconscious
Pupil: ( /1.5)
Cardiovascular ( /3)
Eye
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Racoon eye Discharge Edematous eye lid
Blurred vision
Ear
Ottorrhea Battle's sign Bleeding Discharges
Tinnitus Deafness Decreased acuity
Nose
Rhinorrhea Deformity Discharges Epistaxis
Pain ( /4)
Alleviating factors:……………………………………………………………………………………………………………
Quality: Ache Dull Sharp Stabbing
Cramping Burning Throbbing
Region/Radiation: ………………………………………………………………………………………………………………………………………….
Severity : Mild Moderate Severe very severe worest
≤ 2 no pain
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GIT ( /2.5)
Abdomen:
Soft Firm Flat Rounded
Bowel elimination:
Incontinence Diarrhea Constipation
Feeding method:
Oral NGT feeding Parenteral feeding (TPN)NPO
special diet …………………………………………………………………………………………………………………
Integumentary ( /2.5)
Ecchymosis Hematoma
Swelling Diaphoretic
Sacrum Intact heels Intact elbow Intact
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Extremities (Assess mobility, joint function) ( /3)
Deformity Crepitus Tenderness Stiffness
Weak muscles Paralysis Loss of sensation Numbness
Communication ( /2)
Rest ( /1)
Sleep aids:
Pillows Medication Drinks Others ……………………
Sleep latency /remaining asleep (Insomnia)
Age > 65
History of fall
Taking fall related medication ( analgesics, diuretics, …)
Physical impairement
Cognitive impairement
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Part VI: Patient's Nursing Diagnosis
1……………………………………………………………………………………………………………………………………………
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4…………………………………………………………………………………………………………………………………………….
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6…………………………………………………………………………………………………………………………………………….
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Nursing Record for Patient at Critical unit / 5 marks)
CVP ⁄⁄ 22
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2
1
0
-1
-2
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Time 9 am 10 am 11 am 12 pm 1 pm
M.V Mode
( /1) Fio2
RR
Pt.R
MV.R
VE
Vt.
PEEP/ CPAP
I:E
Hum.Temp.
A.B.G.( PH
/1) PaCO2
HCO3
PaO2
O2 Sat.
Interpretation
Total intake
Output Urine
Drainage
Vomiting
Insensibleloss
Total output
Balance
Lab investigations Type
( /0.5)
Result
Medications( Name
/0.5) Dose
Route
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Nursing Notes
Patients' Receiving
General Care
Specific Care
Signature
NURSING CARE PLAN [ / 10 MARTS ]
Student name ………………………………………………………………
Patient name ………………………………………………………………..
Age …………………………………………….. gender ……………………………………….
DOA ……………………………………………. DOD …………………………………………
SIGNATURE …………………………………………………………………………………………………..
Clinical evaluation sheet
Comment:__________________________________________________________________
Student signature:________________________ Staff signature:…………………………...
Presentation Evaluation Checklist (critical care nursing practical)
Student's name: ………………………… Group: ….… Student's Number: …………
Date: / / Topic Title: ………………… Student assigned to:………….………
Student's
Items Grade Comment
grade
Introduction:
- Introduction of self, starting with warm and precise opening 2
indicating content and capture audience attention
Content
- Objectives clearly stated, comprehensive, accurate and 1.5
organized
- Content good prepared 1.5
Presentation skills
Total degree 10
9. Ease foot section over the client's toe and heel, adjusting as 1
necessary for proper smooth fit.
10. Gently pull the stocking over the leg, removing all wrinkles. 1
16. Documentation: 1
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
17. Set the pacing current output (in milliamperes [mA]). For patients with 1
bradycardia, start with the minimal setting and slowly increase the amount
of energy delivered to the heart by adjusting the ‘Output’ mA dial. Do this
until electrical capture is achieved: you will see a pacer spike followed by a
widened QRS complex and a tall broad T wave that resembles a premature
ventricular contraction.
18. Increase output by 2 mA or 10%. Do not go higher because of the
½
increased risk of discomfort to the patient.
19. Assess for mechanical capture: Presence of a pulse and signs of
½
improved cardiac output (increased blood pressure, improved level of
consciousness, improved body temperature).
20. For patients with asystole, start with the full output. If capture occurs,
1
slowly decrease the output until capture is lost, then add 2 mA or 10% more.
21. Secure the pacing leads and cable to the patient’s body.
½
22. Monitor the patient’s heart rate and rhythm to assess ventricular
½
response to pacing. Assess the patient’s vital signs, skin color, level of
consciousness, and peripheral pulses. Take blood pressure in both arms.
23. Assess the patient’s pain and administer analgesia/sedation, as ordered,
½
to ease the discomfort of chest wall muscle contractions
24. Perform a 12-lead ECG and additional ECG daily or with clinical
½
changes.
25. Continually monitor the ECG readings, noting capture, sensing, rate,
½
intrinsic beats, and competition of paced and intrinsic rhythms. If the
pacemaker is sensing correctly, the sense indicator on the pulse generator
should flash with each beat.
26. Remove PPE, if used. Perform hand hygiene.
½
27. Documentation:
½
Document the reason for pacemaker use, time that pacing began,
electrode locations, pacemaker settings, patient’s response to the procedure
and to temporary pacing, complications, and nursing actions taken.
Document the patient’s pain-intensity rating, analgesia or sedation
administered, and the patient’s response.
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Steps 0 1 2 3
1- Assess the type of central IV catheter, size and number of lumens.
½
2- Assess the patient understanding of need for care.
½
3- Assess the patient allergy to antiseptic solutions.
½
4- Explain procedure to the patient.
½
5- Position of the patient in comfortable position with head
1
slightly elevated.
6- Perform hand hygiene, wear protective measures and apply clean
½
gloves.
7- Remove old dressing in direction of catheter insertion and
1
discard in biohazard container.
8- Remove protective device if present but if use sutures and become
1
loosening using protective device
9- Inspect catheter insertion site and surround skin, for erythema,
1
warmth, tenderness, drainage.
10-Gauze dressing care provided every 48 hrs. , and as needed,
1
transparent dressing care every 7 days and as needed.
11- Remove old gloves, perform hand hygiene. ½
12- Open sterile dressing kit and wear clean gloves.
½
13- Using aseptic swab, cleanse catheter and site as the following: 1
- First swab in horizontal line
- Second swab in vertical line
- Third swab in circular outward motion
14- Allow antiseptic to dry completely.
1
15- Apply new catheter stabilization if not sutured.
½
16- Apply sterile dressing over site.
½
17- Apply label with date, time and initial name
1
18- Dispose equipment's, remove gloves and perform hand washing.
½
19-Observe catheter connection periodically every 8 hours for leaks,
1
tear, secure and correct solution
20- Documentation. 1
- Procedure steps, type of antiseptic solution
- Date and time of procedure
- Reaction of the patient
- Signs and symptoms of inflammation, dislodgement
- Signature of the nurse
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Discard gloves and don sterile ones to insert new cannula. Replace with
appropriately sized new cannula. Engage lock on inner cannula.
14- Applying Clean Dressing and Tape: 1
Dip cotton-tipped applicator in saline and clean stoma under faceplate.
Use each applicator only once, moving from stoma site outward.
15 - Apply hydrogen peroxide to area around stoma, faceplate, 1
and counter cannula if secretions prove difficult to remove. Rinse area
with saline.
16- Pad skin gently with dry " 4x4" gauze. ½
17- Slide commercially prepared tracheostomy dressing or pre ½
folded non-cotton-filled "4x4" dressing under faceplate.
18- Change the tracheostomy tape: 1
a. Leave soiled tape in place until new one is applied.
b. Cut piece of tape that is twice the neck circumference plus in (10
cm). Trim ends of tape on the diagonal.
c. Insert one end of tape through faceplate opening alongside old tape.
Pull through until both ends are even.
d. Slide both tapes under patient's neck and insert one end through
remaining opening on other side of faceplate. Pull snugly and tie
ends in double square knot. Check that patient can flex neck
comfortably.
e. Carefully remove old tape. Reapply oxygen source if necessary. ½
19- Remove gloves and discard. Perform hand hygiene. Assess ½
the patient's respirations. Document assessments and complication
of procedure
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Key: 0 ≡ 0 Mark (Not done) 1 ≡ 1mark (Needs Practice) 2≡ 2marks (Satisfactory) 3≡ 3 marks (Excellent)
Comment----------------------------------------------------------------------------
Student’s Signature-………………………………………………………
Date:
Stamp:
Technical, analytical and management [ / 5 marks ]
A. Course Notes
B. Essential Books
C. Web Sites
With my best wishes