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.
Patients Details & Demographics and Chief Complain

 A patient named Laila Bibi, 42 years female under the care of Dr. Saira Furqan, Admission date -
26-11-23, came into the ER with a complaint of uncontrolled diabetes mellitus and wounds on the
right foot for almost 3 years for which conservative management was done and the wound used to
resolve but for the past 3 months the wounds are not resolving and getting worse which Is treated
with antibiotics and local dressing also used to get fever as a systemic symptom taken home
however despite iv antibiotics and then developed fever and develop right knee pain, swelling

 10 months back, taken to Nishtar Hospital, and I and D attempted on the right knee on 4-11-23 then,
the patient developed SOB, hypertension, orthopnea and fever, and then the amputation of the right
foot was done. SOB could not move at rest due to weakness.
  On assessment, his GCS is 15/15, HR= 94/min, SPO2=99% on 5L Oxygen support, RR=15/min,
BP=148/83, capillary Refill 4-5 seconds and skin turgor average. The patient is restless. The patient
is maintaining output via Foley’s catheter.
 abdomen was soft and non-tender, and bowel sounds were normal.

Diagnosis
 Malaria, osteomyelitis
 Diabetes Mellitus and hypertension

Lab Investigation (Relevant)

 X-ray of the lower extremity femur has shown Vascular calcifications and air
lucencies in the soft tissues of the thigh
 Chest x-ray was normal
 ECG: Normal.
 On arrival in ER the labs were
 Hb  8.9
 Hct  27 Na 133

 MCV  79 K 3.6

 WBC  10 Cl 106

 Neu  85 Cr 0.9

 Lym  10 T.B 3.1

 Plt  179 I.B 0.6

 GGT  53 DB 2.5

 SGPT  7 SGOT 16

 Current Labs10
 Na  137
 K  4.3
 Cl  105
 Cr  0.7
 GGT  43
 SGPT  7
 SGOT  22
 T.B  1.5
 I.B  0.2
 D.B  1.3
 AP  255
  Hb  8.8
 Hct  27
 MCV  82
 WBC  6.9
 Neu  68
 Lym  23
 Plt  356
 ABGS
 PH  7.41
 PCO2  32.7
 PO2  60.7
 HCO3  20.1
 BE  -3.5
 O2 SAT  90.8

Interventions- Pharmacological

 SODIUM CHLORIDE
 ARTEM DS
 LACTATED RINGER SOL
 NalbuPHINE HCL
 SUCRALFATE
 PREGABALIN
 GLYCERIN
 LACTITOL
 KLEEN

Non-Pharmacological
 Patient is CBR
 Diabetic Foot Care: Regularly inspect the remaining foot for any signs of wounds
or infection.
 Lifestyle Modifications: Implement a heart-healthy diet (such as DASH).
 Stress management techniques
Teaching Provided (if done)

 . The patient was encouraged to immobilize the affected part to reduce the spread of infected
material.
 patients with diabetes and kidney problems, diabetes mellitus (DM) is one of the leading causes of
kidney failure in the United States.
 Encouraged the importance of daily hygiene to prevent infection and skin breakdown.
 Educate the patient on the importance of using bed nets treated with insecticide.