POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA

Log book

Trainee’s Name:..abeer naif alanazi Reg No:. 202042722 Date: 28/3/2021 Clinical case No:4
DATADEMOGRAPHIC

Age/Gender: .34year,male
Allergies:.non
Past medical/ surgical history:…-
Mechanism of injury (traumatic injury patients):
Medical diagnosis:pancreatitis

NURSING CARE PLAN

Nursing Diagnosis and Nursing and Multidisciplinary Rationales Evaluation & Admission OR
ASSESSMENT COLLECTION
planning Interventions Discharge plan

Chief Complaint: Nursing Diagnosis 1: Nursing Interventions: ………..

 Abdomen pain …. 1. … 1. …
Subjective Data: Planning: 2. …. 2. …
 Patient say”I have abdominal ... Multidisciplinary interventions:
pain in and vomiting once A. … A. …
 … B. … B. …
Objective data: Nursing Diagnosis 2: Nursing interventions:
Pain score9/10 ... 1. … 1. …
Planning: 2. … 2. …
Physical Examination. … Multidisciplinary interventions:
A. … A. ...
 Abdomen pain and tenderness in
B. … B. …
right lower and extend to back
 … Nursing Diagnosis 3: Nursing interventions:
Vital signs … 1. … 1. …
Element Value Planning: 2. … 2. …
HR 83 … Multidisciplinary interventions:
A. ... A. …
RR 18
B. … B. …
BP 118/77
SPO2 98
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 POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA
Log book
Temp
GCS
--/15
Lab Studies
CBC:
Value Normal
Element Value
Range
WBC 4-10 10^9/L
3.8 4.8
RBC
10^9/L
HGB 12-15 g/dL
HCT 36-46 %
150-410
Platelet
10^9/L
Biochemistry:
Normal
Element Value Value
Range
3.9-6.1
GLU
mmol/L
2.5-8.3
UREA
mmol/L
44-115
CREA
umol/L
0-18
Bilirubin
umolL
136-145
Sodium
mmol/L
Potassium 3.5-5.1
2.06-2.5
Calcium
mmol/L

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 POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA
Log book
15-37
AST
U/L
30-65
ALT
U/L
Total 60-85
Protein g/l
30-50
Albumin
g/l
1.3-6.1
Cholesterol
mmol/L
ABG/VBG
Normal
Element Value Value
Range
7.35-7.45
PH
7.25-7.35
35-45
PaCO2 41-51
mmHg
21-27
HCO3
mEq/L
80-100
PaO2 35-40
mmHg
Coag profile
Normal
Element Value Value
Range
pt Sec 11-16
ptt Sec 26-36
INR 0.9-1.4
Diagnostic Studies:

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 POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA
Log book
 …
 …
PATHOPHSIOLOGY

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 POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA
Log book

Date: _______________ Case: _______________________________________________________________

Total score: _______ / 10 Evaluator Name and Signature: ___________________________________________

The following will be displayed on forms where feedback is

No. Criteria 1 2 3 4 5 enabled...
1 ASSESSMENT: Biographic Data (for the evaluator to answer...)
*Did you have an opportunity to meet with this resident to discuss their
ASSESSMENT: History (Chief complaint, Illness History (of the current
2 performance?
disease), Past Medical History, and Family History)
3 ASSESSMENT: physical assessment head to toe and system by system Yes

4 ASSESSMENT: Diagnostic Procedures No

5 ASSESSMENT: Lab Investigations (indicate abnormal lab results) (for the trainee to answer...)
*Are you in agreement with this assessment?
6 TREATMENT: pharmacological and Non-pharmacological
Yes
NURSING DIAGNOSIS using NANDA terminology and format, and list
7
Diagnosis according to the priority No
PLANNING for patient care (Goals and Objectives ordered according the
8
priority)
NURSING INTERVENTION: actions done based on the nursing planning
9
made by the trainee
EVALUATION: reassessment of the patient to figure out the effectiveness
10
of nursing intervention completed by the trainee
Please enter any comments you have (if any) on this evaluation

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 POST GRADUATE PROGRAM: EMERGENCY NURSING DIPLOMA
Log book
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