Daily CLINICAL EXPERIENCE LOG

Date: 23/11/2022 Site: CICU Preceptor: Dr. Jihad & Dr. Anas

Therapeutic Nursing
Age/Sex Diagnosis Pertinent Assessment Findings Interventions
61 male DX: The HX: Nursing Diagnosis:
decreased  Medical Hx: IHD, last 1.Impaired Gas Exchange
level of cath in 2013, 7 stents. related to Altered oxygen
consciousness  History of recent COPD supply (obstruction of
and COPD and DM diagnosis airways by secretions,
 Recently COPD bronchospasm; air-
CC: patient exacerbation admission to trapping), Alveoli
said” I have ICU in prince rashed destruction, Alveolar-
had difficulty hospital, discharged 10 capillary membrane
breathing and days ago. changes evidenced by
feeling of  Heavy smoker 2 packs changes in ABGS,
dizziness for daily hypercapnia, CTA report,
2 days ”  no previous surgeries, no change in vital signs o2
known drug or food sat less than 92% .
allergies
HPI:
The patient was admitted Desired Outcomes
according to his family when they
noticed his decreased level of The client will
consciousness, increased dry demonstrate improved
cough, and shortness of breath, ventilation and adequate
his blood pressure was found oxygenation of tissues by
80/50, and his status of bedridden ABGs within the
was since 1 month. Co2 was patient’s normal range
found 102 patient with co2 and be free of symptoms
retention so the patient was put on of respiratory distress.
BiPAP in ER and transferred to
ICU department.
2. impaired physical
Abnormal Labs results: mobility related to
WBC 12.2 increased. 4-9 Imbalanced between
H.B 8 g/d decreased 13-16 oxygen supply and
HCT 23.6 decreased 35-45 demand due to inefficient
Plt 410 high 150-400 work of breathing,
anemia and disease
- Creatinine 25.9umol/l low (62- process evidenced by
115) patient status of
- calcium 2.3 low mmol/l 2.2- bedridden.
2.7
- PCO2 59 high 35-45
respiratory acidosis
HCO3 38 high 22-26
-ECG: PVCS
-Chest x-ray: right lower lobe
consolidation.
- ECHO: good LV function,
sclerotic aortic valve, trace TR
RVSP= 55 MMHG
Chest CTA report: consolidation
in the lateral and posterior
segment of the right lower lobe,
several intraparenchymal nodules,
and hypertdense foreign material
seen in the right lower bronchus.
Current Medications:
Methylprednisolone iv 500mg *3
Levofloxacin iv 500mg * 1
Lansoprazole po 30mg *1
Tinam 1000mg iv *3
b.aspirin 100mg *1
enoxaparin 40mg s.c
Lipitor 40mg * 1
Combivent NEB * 4
Plavix 75mg *1
Lasix iv 40mg *1
Normal saline iv 0.9 % 80cc/hrs
Vitals:
BP: 116/76 mmHg
RR: 18 B/min
Pulse: 88 B/minute
T: 36.7 °C
Current Pain: 2/10
O2 sat: 91% on nasal cannula
GCS: 13
Braden risk assessment for
pressure sore (mild risk)
Morese fall scale patient at high
risk related to his disease
With folyes catheter
Wt: 75 kg
Desired outcomes:
Patient performs physical
activity independently or
within limits of the
disease.
Patient demonstrates
measures to increase
mobility
3. impaired skin integrity
r/t immobility and
disease process
evidenced by pressure
ulcer 2nd degree on scaral
area.
Desired outcomes:
The patient reports any
altered sensation or pain
at site of tissue
impairment.
The patient demonstrates
an understanding of plan
to heal tissue and prevent
injury.
Nursing interventions:
1.Assess and record
respiratory rate, and
depth. Note the use of
accessory muscles,
pursed-lip breathing,
and inability to speak or
converse.
2. Assess and routinely
monitor skin and
mucous membrane
color. Cyanosis may be
Ht: 170 cm
The patient looks now conscious
but sometimes disoriented to time
and place persons sometimes
confused, does not communicate
well, and does not fully obey
commands, he has a pressure
ulcer 2nd degree on the sacral area
1 cm with no sign of infection,
BIPAP hold now keeps it PRN,
on nasal cannula flow rate 5
liter/min, o2 92%, mild dyspnea
with crackles lung breath sounds
bilateral. patient on low salt and
DM diet with a high protein
diet.The patient expressed
discomfort from sacral area
related to pressure injury.
peripheral (noted in
nail beds) or central
(noted around lips/or
earlobes). Duskiness and
central cyanosis indicate
advanced hypoxemia.
3. Monitor changes in the
level of consciousness
and mental status.
Restlessness, agitation,
and anxiety are common
manifestations of
hypoxia. Worsening
ABGs accompanied by
confusion/ somnolence
are indicative of cerebral
dysfunction due to
hypoxemia.
4. Monitor vital signs
and cardiac rhythm.
Tachycardia,
dysrhythmias, and
changes in BP,
Auscultate breath
sounds, noting areas of
decreased airflow and
adventitious sounds.
Breath sounds may be
faint because of
decreased airflow or
areas of consolidation. 
5.Monitor O2 saturation
and titrate oxygen to
maintain Sp02 between
88% to 92%.
6.Monitor arterial
blood gas values as
ordered.
7.Evaluate the client’s
level of activity
tolerance

8.Encourage
expectoration of
sputum; suction when
needed.

9.Elevate the head of the

bed, and assist the client
to assume a position to
ease the work of
breathing. Include
periods of time in
aprone position as
tolerated. 

10Encourage deep-slow
or pursed-lip breathing
as individually needed
or tolerated.

11.Provide a calm, quiet

environment. Limit the
client’s activity or
encourage bed or chair
rest during the acute
phase. Have the client
resume activity
gradually and increase
as individually
tolerated.

12.Administering
humidified oxygen
prevents drying out the
airways, decreases
convective moisture
losses, and improves
compliance.

Give packed RBCS as

doctor order and monitor
hemoglobin level daily

13. Assist patient for

muscle exercises as able
or when allowed out of
bed; execute abdominal-
tightening exercises and
knee bends; hop on foot;
stand on toes.

14. Present a safe

environment: bed rails
up, bed in a down
position, important items
close by.

15. Establish measures to

prevent skin breakdown
and thrombophlebitis
from prolonged
immobility:
 Clean, dry, and
moisturize skin as
necessary. Use anti
embolic stockings or
sequential compression
devices if appropriate.
Use pressure-relieving
devices as indicated (gel
mattress).

16. Execute passive or

active assistive ROM
exercises to all
extremities.

17. Provide foam or

flotation mattress, water
or air mattress or kinetic
therapy bed, as
necessary.

18. Promote and facilitate

early ambulation when
possible. Aid with each
initial change: dangling
legs, sitting in chair,
ambulation.

19. Encourage coughing

and deep-breathing
exercises. use suction as
necessary. Make use of
incentive spirometer.

20.Turn and position the

patient every 2 hours or
as needed.

21. Encourage a diet high

in fiber and liquid intake
of 2000 to 3000 ml per
day unless
contraindicated. Set up a
bowel program (e.g.,
adequate fluid, foods
high in bulk, physical
activity, stool softeners,
laxatives) as needed.
Note bowel activity
levels.

22. Assess each shift the

site of impaired tissue
integrity and its
condition, characteristics
of the wound, including
color, size (length, width,
depth), drainage, and
odor.

23. Assess changes in

body temperature,
specifically increased
body temperature. Assess
the patient’s level of pain

24.Monitor site of
impaired tissue integrity
at least once daily for
color changes, redness,
swelling, warmth, pain,
or other signs of infection

25.Monitor the status of

the skin around the
wound. Monitor patient’s
skincare practices, noting
the type of soap or other
cleansing agents used, the
temperature of the water,
and frequency of skin
cleansing.

26.Assess patient’s
nutritional status; refer
for a nutritional
consultation or institute
dietary supplements.
Inadequate nutritional
intake places the patient
at risk for skin
breakdown and
compromises healing,
causing impaired tissue
integrity.

27.refer to wound care

specialist to Provide
tissue care as needed.

28. Keep a sterile

dressing technique during
wound care.

29. Monitor patient’s

continence status and
minimize exposure of
skin impairment site and
other areas to moisture
from
incontinence perspiration,
or wound drainage.
Prevents exposure to
chemicals in urine and
stool that can strip or
 erode the skin causing
further impaired tissue
integrity.

30. Encourage the use of

pillows, foam wedges,
and pressure-reducing
devices To prevent
pressure injury.

31. Do not position the

patient on the site of
impaired tissue integrity.
If ordered, turn and
position the patient at
least every two (2) hours
and carefully transfer the
patient. This is to avoid
the adverse effects of
external mechanical
forces (pressure, friction,
and shear).

32. Maintain the head of

the bed at the lowest
degree of elevation
possible. To reduce shear
and friction.

33. sent swab cx if ulcer

looks infected and give
antibiotic as needed.

34. Educate the client

regarding smoking
cessation

Log experience submission for date: 23/11/2022

 A Summarization of the Leaning Synthesis from the Day’s Experiences:
Effects of inspiratory muscle training in COPD patients
In systematic review with meta-analysis study that was conducted to verify the effect of
inspiratory muscle training IMT using threshold devices in COPD patients on dyspnea,
quality of life, exercise capacity, and inspiratory muscles strength, and the added effect on
dyspnea of IMT associated with pulmonary rehabilitation (vs. PR alone).
Devices for inhalatory muscle training (IMT) have been in use for a while. It has been
shown to improve exercise capacity, dyspnea, and quality of life, and long-term therapy is
necessary to keep these effects. IMT works well both on its own and in combination with
pulmonary rehabilitation treatments. However, there is little evidence that IMT is
effective for treating dyspnea when combined with pulmonary rehabilitation.
In this systematic review IMT devices were very effective in strengthening the inspiratory
muscle, increased exercise capacity, the effect on dyspnea and quality of life no
significantly different from pulmonary rehabilitation alone. (Beaumont et al., 2018)

References

Beaumont, M., Forget, P., Couturaud, F., & Reychler, G. (2018). Effects of inspiratory muscle

training in COPD patients: A systematic review and meta‐analysis. The Clinical

Respiratory Journal, 12(7), 2178–2188.

Agarwal, A. (2022, August 8). Chronic Obstructive Pulmonary Disease – StatPearls. NCBI.

Retrieved November 15, 2022.

Ambrosino, N., & Bertella, E. (2018, September). Lifestyle interventions in prevention and

comprehensive management of COPD. Breathe, 14(3).

Daily Objective addressed/accomplished:
At the end of this clinical day I will be able to:

1. Provide complete comprehensive nursing care for patients with COPD.

2. Establish effective health teaching and education preventive strategies COPD
exacerbations.
3. Perform a thorough assessment and physical exam to patient with COPD.
4. Apply comprehensive pulmonary physical examination for patients with COPD.
5. Encourage the patient to change his life styles like quitting smoking and arranging an
exercise program for physical activity to enhance the quality of life.