1

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

Note
S: feeling like frequency
heavy object Short term outcomes; Goal Met: After
urgency, buring, hours of nursing
staying on my 1. A toileting
chest with After 2 h nursing intervention the
Set a toileting schedule patient had:
pain score of intervention the patient
2/10 , will: schedule guarantees the
difficult of patient of a 1. experienced
breathing and Impaired 1. Patient will designated time fewer dyspne
fatigue Bladder Elimination  demonstrate episodes, with
“Verbalize by related to hemodynamic for voiding and
no syncope or
patient.  neuromuscular impairmen stability Place an reduces episodes dizzy spells.
t ( blood of functional Maintained
pressure, heart appropriate,
incontinence normal
rate, safe urinary respiratory
respiratory receptacle 2. The patient must status.
O: rate) to
such as a 3-in- take this With vs
Notice facial normalized or alternative Rr: 20
grimace 2  by 20%-30% 1 commode,
Hr: 102
as revealed by female or toileting facility.
Bp:
SOB with the cardiac male hand- Some people may 148/92mmHg
exertion monitor be ashamed when
↓ SpO2 held urinal,
Tachycardia no-spill urinal, using a toilet in a
or more open area.
containment 3. Restricting fluid .

device when intake and voiding

Vital signs:
Temp: 36.6 toileting before bedtime
Bp: 163/136 access is reduces the need
mmHg to
P:111 limited by
RR: 22bpm disrupt sleep for
2
Spo2:90%- immobility or voiding.
91% room air
environmental
barriers.
Provide
privacy.

Tell the patient

to limit fluid
intake 2 to 3
hours before
bedtime and
to void just
before
bedtime.

4.Administer oxygen to
the patient as prescribed
by the physician.

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