Clinical Log Sheet

Student Name: Uzma Bibi

Clinical Hours/week: week 1

Day 1
8 hours
Evening Shift

Date: From: 29-11-23 To: 29-11-23

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.
11. Attend clinical rounds with the attending physician for better understanding.

Patients Details & Demographics and Chief Complain

 Patient named Mahmood Zafar, 70 years male under the care of Dr. M Irfan, Admission date 24-11-
23, came into the ER with a complaint of Fever for 2 days, productive cough, and shortness of
breath.
 According to the patient attendant, the fever was relieved after 2 tabs of Panadol every 8 hours.
 He had a history of Hemolytic anemia and is on immunosuppressant.
 SOB could not move at rest due to weakness.
 On assessment, his GCS is 15/15, HR= 97/min, SPO2=99% on 8L Oxygen support, RR=28/min,
BP=140/64, capillary Refill 1-2 seconds and skin turgor average. The patient is restless. The patient
is maintaining output via Foley’s catheter.
 Bilateral Crept and wheezing were present on auscultation; the abdomen was soft and non-tender,
and bowel sounds were in the normal range.
  Diagnosis
 Viral pneumonia
 Diabetes Mellitus and hypertension

Lab Investigation (Relevant)

 HRCT has shown patchy GGOS and parenchymal cysts.
 X-ray Chest has shown Re demonstration of airspace shadowing in bilateral lung
fields, predominantly involving both upper lung zones and the left lower lung
zone, unchanged since the prior examination.
 ECG: Normal.
 On arrival in ER, the labs were
 Hb  10.3
 Hct  29.3 Na 124

 MCV  95.4 K 3.8

 WBC  5.7 Cl 91

 Neu  81.5 Cr 1.1

 Lym  11.8 HbA1c 6.6

 Plt  91
 
 

 Current Labs10
 Na  134
 K  3.6
 Cl  95
 Cr  1.2
 
 
 
 
 
 Hb  10.0
 Hct  28.9
 MCV  90.6
 WBC  5.9
  Neu  87.6
 Lym  9.2
 Plt  128
 ABGS
 PH  7.46
 PCO2  33.6
 PO2  67.7
 HCO3  23.1
 BE  -1.0
 O2 SAT  94.2

Interventions- Pharmacological

 HUMALOG
 CO-TRIMOXAZOLE
 PIP/TAZO
 GLARGINE
 FUROSEMIDE 20mg
 POTASSIUM CHLORIDE
 METHYLPREDNISOLONE
 OMEPRAZOLE

Non-Pharmacological
 Patient is CBR
 On oxygen support 8 liters.
 Risk fall assessment
 Rest and Hydration
 Chest Physiotherapy
 Deep Breathing Exercises
Teaching Provided (if done)

 Explain the nature of viral pneumonia, emphasizing that a virus causes it and may present with
symptoms such as cough, fever, shortness of breath, and chest pain.
 Educate on the modes of transmission, highlighting the importance of good hand hygiene to prevent
the spread of the virus.
 Teach the patient the recognition of early symptoms of pneumonia
 Guide about the use of spirometry
 Encourage the patient to a healthy lifestyle, including a balanced diet rich in nutrients to support the
immune system.